Nursing Elites

1. A nurse is assessing a client who has been taking haloperidol for several years. Which of the following assessment findings should the nurse recognize as a long-term side effect of this medication?

• A. Lipsmacking
• B. Agranulocytosis
• C. Clang association
• D. Alopecia

Correct answer: A

Rationale: Lipsmacking is a common sign of tardive dyskinesia, a long-term side effect of haloperidol. Tardive dyskinesia is characterized by repetitive, involuntary, purposeless movements such as lipsmacking, tongue protrusion, and facial grimacing. Agranulocytosis (choice B) is a potential side effect of antipsychotic medications but is not specifically associated with haloperidol. Clang association (choice C) is a form of disorganized speech seen in conditions like schizophrenia but is not a side effect of haloperidol. Alopecia (choice D) refers to hair loss and is not a common long-term side effect of haloperidol.

2. A nurse is caring for a client who has a new prescription for metformin. Which of the following instructions should the nurse include?

• A. Take this medication on an empty stomach.
• B. You should avoid eating foods high in potassium.
• C. You should take this medication with meals to improve absorption.
• D. Take this medication before bed to prevent drowsiness.

Correct answer: C

Rationale: The correct instruction for a client prescribed metformin is to take the medication with meals to improve absorption and reduce gastrointestinal upset. Metformin is typically recommended to be taken with food to minimize side effects. Option A is incorrect as taking metformin on an empty stomach may increase the risk of gastrointestinal side effects. Option B is unrelated as metformin does not interact with potassium-rich foods. Option D is also incorrect as metformin does not cause drowsiness, so there is no need to take it before bed.

3. A client who has a new prescription for prednisone is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will avoid taking this medication with food.
• B. I will need to take this medication for the rest of my life.
• C. I will take this medication for 2 weeks and then stop.
• D. I will take this medication with a high-protein snack.

Correct answer: B

Rationale: The correct answer is B because prednisone is usually prescribed for long-term use. Stopping it abruptly can lead to adrenal insufficiency. Choice A is incorrect because prednisone should be taken with food to prevent stomach upset. Choice C is incorrect as prednisone is typically tapered off gradually to avoid adverse effects. Choice D is incorrect as there is no specific requirement to take prednisone with a high-protein snack.

4. A client who is receiving continuous enteral feedings through a nasogastric tube needs preventive measures to avoid aspiration. Which of the following actions should the nurse take?

• A. Elevate the head of the bed to 30 degrees.
• B. Check gastric residual volumes every 4 hours.
• C. Administer the feeding at room temperature.
• D. Flush the feeding tube with 20 mL of water every 8 hours.

Correct answer: B

Rationale: The correct answer is to check gastric residual volumes every 4 hours. This action helps prevent aspiration by ensuring the stomach is emptying properly, reducing the risk of reflux and aspiration. Elevating the head of the bed to 30 degrees can help prevent aspiration by promoting proper digestion and reducing the risk of regurgitation. Administering the feeding at room temperature is important for patient comfort but does not directly prevent aspiration. Flushing the feeding tube with water every 8 hours is important for tube patency but does not directly prevent aspiration.

5. A nurse is assessing a client who is 30 minutes postoperative following an arterial thrombectomy. What should the nurse report?

• A. Chest pain.
• B. Muscle spasms.
• C. Cool, moist skin.
• D. Incisional pain.

Correct answer: A

Rationale: In this scenario, postoperative chest pain is a critical finding that must be reported promptly. Chest pain after an arterial thrombectomy could indicate serious complications such as myocardial infarction or pulmonary embolism. Muscle spasms and cool, moist skin are not the priority assessments in this situation. Incisional pain is common after surgery and is not typically a cause for immediate concern unless it is severe and accompanied by other symptoms.

Similar Questions