Nursing Elites

1. In an acute mental health facility, a patient experiencing opioid withdrawal has a new prescription for Clonidine. What action should the nurse identify as the priority?

• A. Administer the Clonidine as prescribed.
• B. Provide ice chips to the patient.
• C. Educate the patient on Clonidine's effects.
• D. Obtain baseline vital signs.

Correct answer: D

Rationale: In this scenario, the priority action for the nurse is to obtain baseline vital signs. This is essential for establishing a baseline assessment, especially for a patient undergoing opioid withdrawal and starting a new medication like Clonidine. Monitoring vital signs is crucial for evaluating the patient's response to treatment and detecting any potential complications early on. Administering the medication, providing ice chips, and educating the patient on Clonidine's effects are important tasks but obtaining baseline vital signs takes precedence to ensure the patient's safety and proper management.

2. A client who takes Chlorpromazine for the treatment of Schizophrenia is due for a follow-up assessment. The nurse should expect the greatest improvement in which of the following manifestations? (Select all that apply.)

• A. Disorganized speech.
• B. Bizarre behavior.
• C. Impaired social interactions.
• D. Hallucinations.

Correct answer: A

Rationale: When a client takes a conventional antipsychotic medication like chlorpromazine, the greatest improvement is typically seen in positive symptoms such as disorganized speech. These medications are more effective in managing positive symptoms like disorganized speech rather than negative symptoms like impaired social interactions or hallucinations. Therefore, the nurse should anticipate improvement in disorganized speech as a positive response to chlorpromazine treatment.

3. A client is receiving Morphine IV for pain management. Which of the following actions should the nurse take to monitor for adverse effects?

• A. Monitor the client's respiratory rate every 15 minutes.
• B. Monitor the client's blood pressure every 30 minutes.
• C. Monitor the client's oxygen saturation every hour.
• D. Monitor the client's heart rate every 5 minutes.

Correct answer: A

Rationale: The correct action for the nurse to monitor for adverse effects of Morphine IV is to check the client's respiratory rate every 15 minutes. Respiratory depression is a potentially life-threatening adverse effect of Morphine. Monitoring the respiratory rate frequently allows for early detection and intervention if needed. Monitoring blood pressure, oxygen saturation, or heart rate alone may not provide early signs of respiratory depression, which is a critical adverse effect of Morphine IV.

4. A client has a new prescription for Furosemide. Which of the following adverse effects should the nurse monitor?

• A. Hyperkalemia
• B. Hyponatremia
• C. Hypernatremia
• D. Hypercalcemia

Correct answer: B

Rationale: Furosemide is a diuretic that commonly causes hyponatremia (low sodium levels) due to its effect on sodium and water excretion. The nurse must closely monitor the client for signs of hyponatremia, such as weakness, confusion, and muscle cramps, and promptly intervene to prevent complications. Choices A, C, and D are incorrect because Furosemide is not associated with hyperkalemia, hypernatremia, or hypercalcemia. Understanding the medication's mechanism of action helps prioritize monitoring for potential adverse effects.

5. A client has a new prescription for Omeprazole. Which of the following statements should the nurse include in teaching the client?

• A. Take the medication before meals.
• B. You may experience a rapid heart rate.
• C. Increase your intake of high-calcium foods.
• D. Expect your urine to turn orange.

Correct answer: A

Rationale: The correct statement for the nurse to include when teaching a client prescribed Omeprazole is to take the medication before meals. Omeprazole, a proton pump inhibitor, is most effective when taken before meals as it works by reducing the amount of acid produced in the stomach. Choice B is incorrect because a rapid heart rate is not a common side effect of Omeprazole. Choice C is incorrect as there is no specific requirement to increase intake of high-calcium foods with Omeprazole. Choice D is also incorrect as Omeprazole does not typically cause urine discoloration.

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