Nursing Elites

1. During an admission assessment for a client with severe Aspirin toxicity, what finding should the nurse expect?

• A. Body temperature 35°C (95°F)
• B. Lung crackles
• C. Cool, dry skin
• D. Respiratory depression

Correct answer: D

Rationale: In severe Aspirin toxicity, respiratory depression can occur due to increasing respiratory acidosis. Aspirin toxicity leads to metabolic acidosis, stimulating the respiratory center in the brain to increase the respiratory rate initially. However, as the toxicity worsens, respiratory muscle fatigue and depression can occur, resulting in respiratory depression. This can lead to hypoxia, respiratory failure, and ultimately, respiratory arrest.

2. A client has a new prescription for clonidine to treat hypertension. Which of the following instructions should the nurse include?

• A. Discontinue the medication if a rash develops.
• B. Expect increased salivation during the first few weeks of therapy.
• C. Avoid driving until the client's reaction to the medication is known.
• D. Stop the medication if you experience a dry mouth.

Correct answer: C

Rationale: The correct instruction for a client starting clonidine therapy for hypertension is to avoid driving until their reaction to the medication is known. Clonidine can cause drowsiness, so it is important for the client to refrain from activities that require alertness until they are aware of how the medication affects them. Choice A is incorrect because a rash is not a common side effect of clonidine. Choice B is incorrect as increased salivation is not an expected side effect of clonidine. Choice D is also incorrect as dry mouth is a common side effect of clonidine, but it is not a reason to stop the medication unless severe or bothersome. Therefore, the priority instruction for the nurse to include is to advise the client to avoid driving until their reaction to the medication is known to ensure safety.

3. A client with increased intracranial pressure is receiving Mannitol. Which finding should the nurse report to the provider?

• A. Blood glucose 150 mg/dL
• B. Urine output 40 mL/hr
• C. Dyspnea
• D. Bilateral equal pupil size

Correct answer: C

Rationale: The correct answer is C: Dyspnea. Dyspnea is a concerning finding in a client receiving Mannitol as it can be a manifestation of heart failure, which is an adverse effect of the medication. The nurse should promptly notify the provider, discontinue the Mannitol, and initiate appropriate interventions to address the dyspnea and monitor the client's condition closely. Choice A, Blood glucose of 150 mg/dL, is within normal limits and not directly related to Mannitol administration. Choice B, Urine output of 40 mL/hr, could indicate decreased renal perfusion, but it is not the most critical finding compared to dyspnea. Choice D, Bilateral equal pupil size, is a normal neurological finding and not directly related to Mannitol therapy.

4. A client is being educated by a healthcare provider about a new prescription for Digoxin. Which of the following client statements indicates an understanding of the teaching?

• A. I will take the medication with a high-fiber meal.
• B. I should report any vision changes to my healthcare provider.
• C. I will take the medication if my heart rate is below 60 bpm.
• D. I should avoid dairy products while taking this medication.

Correct answer: B

Rationale: The correct answer is B. Visual disturbances, such as blurred vision or seeing halos, can be a sign of digoxin toxicity. It is crucial for the client to report any changes in vision to their healthcare provider promptly to prevent serious complications. Choice A is incorrect because taking Digoxin with a high-fiber meal can affect its absorption. Choice C is incorrect because taking Digoxin based on heart rate alone is not recommended without healthcare provider supervision. Choice D is incorrect because there is no specific interaction between Digoxin and dairy products.

5. When teaching the family of a child with Cystic Fibrosis about a new prescription for Acetylcysteine, which information should the nurse include?

• A. Expect this medication to suppress your cough.
• B. Expect this medication to smell like rotten eggs.
• C. Expect this medication to cause euphoria.
• D. Expect this medication to turn your urine orange.

Correct answer: B

Rationale: The correct answer is B: 'Expect this medication to smell like rotten eggs.' Acetylcysteine contains sulfur, which gives it a characteristic rotten-egg odor. This odor is normal and expected when using this medication. Choices A, C, and D are incorrect because Acetylcysteine is not used to suppress cough, cause euphoria, or change urine color. Educating the family on the distinct smell of Acetylcysteine will help them understand its characteristics and alleviate concerns about the odor.

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