Nursing Elites

1. When admitting a client and completing a preassessment before administering medications, which of the following data should the nurse include? (Select all that apply.)

• A. Use of herbal teas
• B. Daily fluid intake
• C. Current health status
• D. Previous surgical history

Correct answer: A

Rationale: The correct answer is A, 'Use of herbal teas.' The nurse should inquire about the client's use of herbal teas because they often contain caffeine, which can impact medication biotransformation. This information is crucial to ensure the safe and effective administration of medications and to prevent potential drug interactions. Choice B, 'Daily fluid intake,' while important for overall assessment, is not directly related to medication administration. Choice C, 'Current health status,' is essential but not specific to medication administration preassessment. Choice D, 'Previous surgical history,' although relevant for a client's medical history, is not directly linked to medication administration preassessment.

2. A patient is prescribed warfarin therapy for an artificial heart valve. Which of the following laboratory values should the nurse monitor for a therapeutic effect of warfarin?

• A. Hemoglobin
• B. Prothrombin time (PT)
• C. Bleeding time
• D. Activated partial thromboplastin time (aPTT)

Correct answer: B

Rationale: The correct answer is to monitor Prothrombin time (PT) when a patient is on warfarin therapy. Warfarin affects blood clotting, and PT is used to assess the therapeutic effect of this medication. Hemoglobin (Choice A) is not directly affected by warfarin therapy and does not reflect its therapeutic effect. Bleeding time (Choice C) measures the time it takes for bleeding to stop after a standardized cut and is not specific to warfarin therapy. Activated partial thromboplastin time (aPTT) (Choice D) is more commonly used to monitor heparin therapy, not warfarin.

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

• A. Dry cough
• B. Weight gain
• C. Diarrhea
• D. Nausea

Correct answer: A

Rationale: The correct answer is A: Dry cough. A persistent dry cough is a common adverse effect of Enalapril, an ACE inhibitor. Enalapril can cause the accumulation of bradykinin, leading to cough. Monitoring for a persistent dry cough is crucial as it may indicate the need for further evaluation and possible medication adjustment. Choices B, C, and D are not typically associated with Enalapril use and are less likely to be monitored as adverse effects.

4. A client has a new prescription for Clonidine. Which of the following instructions should the nurse include?

• A. Expect to feel drowsy.
• B. Increase your intake of high-potassium foods.
• C. Take the medication with grapefruit juice.
• D. Avoid foods high in fat.

Correct answer: A

Rationale: The correct answer is to expect to feel drowsy. Clonidine is known to cause drowsiness, especially at the beginning of treatment. It is important for clients to be cautious with activities that require alertness until they understand how the medication affects them. Choice B is incorrect as there is no specific need to increase high-potassium foods with Clonidine. Choice C is incorrect as grapefruit juice can interact with many medications but is not a typical instruction for Clonidine. Choice D is incorrect as there is no specific indication to avoid foods high in fat with Clonidine.

5. A healthcare professional is preparing to administer eye drops to a client. Which of the following actions should the healthcare professional take? (Select all that apply.)

• A. Have the client lie on their side.
• B. Ask the client to look up at the ceiling.
• C. Tell the client to blink when the drops enter their eye.
• D. Drop the medication into the center of the client's conjunctival sac.

Correct answer: B

Rationale: When administering eye drops, it is essential to ask the client to look up at the ceiling. This position helps prevent the drops from falling onto the cornea, ensuring that the medication is properly absorbed without causing discomfort or irritation.

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