Nursing Elites

1. A nurse is assessing a client who has just received an opioid medication. Which of the following findings should the nurse monitor first?

• A. Constipation.
• B. Drowsiness.
• C. Orthostatic hypotension.
• D. Respiratory depression.

Correct answer: D

Rationale: When a client receives an opioid medication, the nurse should first monitor for respiratory depression as it is a life-threatening adverse effect associated with opioids. This can lead to inadequate ventilation and hypoxia, requiring immediate intervention. Constipation, drowsiness, and orthostatic hypotension are also common side effects of opioids but are not as immediately life-threatening as respiratory depression.

2. A nurse is preparing to perform tracheostomy care for a client. Which of the following actions should the nurse take first?

• A. Apply a sterile dressing.
• B. Suction the tracheostomy.
• C. Remove the inner cannula.
• D. Clean the stoma with sterile saline.

Correct answer: B

Rationale: Suctioning the tracheostomy should be performed first to clear the airway of secretions and ensure proper oxygenation before proceeding with other care. This helps maintain a patent airway and prevent complications such as aspiration. Applying a sterile dressing, removing the inner cannula, or cleaning the stoma can follow after ensuring adequate airway clearance through suctioning.

3. A client with a new diagnosis of hypertension is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will decrease my potassium intake while taking this medication.
• B. I will need to take medication for the rest of my life.
• C. I will avoid using salt substitutes.
• D. I will avoid drinking grapefruit juice.

Correct answer: C

Rationale: The correct answer is C. Clients with hypertension should avoid salt substitutes because they often contain potassium, which can raise potassium levels. Choice A is incorrect as decreasing potassium intake is not necessary unless advised by a healthcare provider. Choice B is incorrect as not all clients with hypertension need to take medication for life. Choice D is incorrect as grapefruit juice does not significantly impact hypertension management.

4. A nurse is caring for a client who is receiving TPN. Which of the following actions should the nurse take to prevent infection?

• A. Change the TPN tubing every 72 hours.
• B. Monitor the client's blood glucose every 4 hours.
• C. Monitor the client's urine output every 8 hours.
• D. Use sterile technique when changing the central line dressing.

Correct answer: D

Rationale: The correct answer is D: 'Use sterile technique when changing the central line dressing.' When caring for a client receiving TPN, it is crucial to maintain aseptic technique to prevent infections. Changing the central line dressing with sterile technique helps reduce the risk of introducing pathogens into the client's system. Choices A, B, and C are incorrect because changing the TPN tubing every 72 hours, monitoring blood glucose, and monitoring urine output are important aspects of care but are not directly related to preventing infection in clients receiving TPN.

5. Which lab value should be closely monitored for a patient receiving heparin therapy?

• A. Monitor aPTT
• B. Monitor INR
• C. Monitor potassium levels
• D. Monitor sodium levels

Correct answer: A

Rationale: The correct answer is to monitor aPTT. Activated Partial Thromboplastin Time (aPTT) is crucial to monitor when a patient is receiving heparin therapy. Heparin works by potentiating antithrombin III, leading to the inhibition of thrombin and factor Xa. Monitoring aPTT helps ensure the patient is within the therapeutic range for heparin, reducing the risk of bleeding complications. Monitoring INR (Choice B) is more relevant for patients on warfarin therapy. Monitoring potassium (Choice C) and sodium levels (Choice D) is important but not specific to heparin therapy.

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