Nursing Elites

1. When caring for a client prescribed azithromycin, what should the nurse monitor?

• A. Liver function
• B. Signs of diarrhea
• C. Blood glucose levels
• D. Serum electrolytes

Correct answer: B

Rationale: The correct answer is to monitor signs of diarrhea when a client is prescribed azithromycin. Azithromycin is known to cause gastrointestinal side effects, particularly diarrhea. Monitoring for diarrhea is crucial to assess the client's response to the medication and to prevent complications such as dehydration. Monitoring liver function (choice A), blood glucose levels (choice C), and serum electrolytes (choice D) are not typically indicated specifically for clients prescribed azithromycin unless there are other specific reasons or conditions that warrant such monitoring.

2. A client is prescribed warfarin for anticoagulation. Which of the following laboratory values should the nurse monitor?

• A. PT and INR
• B. Blood glucose levels
• C. Complete blood count (CBC)
• D. Platelet count

Correct answer: A

Rationale: The correct answer is A: PT and INR. Warfarin is an anticoagulant that affects the clotting mechanism by inhibiting vitamin K-dependent clotting factors. The PT (Prothrombin Time) and INR (International Normalized Ratio) are specific laboratory values used to monitor the effectiveness and safety of warfarin therapy. These values help healthcare providers adjust the warfarin dosage to maintain the desired level of anticoagulation. Choices B, C, and D are incorrect because blood glucose levels, complete blood count (CBC), and platelet count are not directly monitored to assess the effects of warfarin therapy.

3. A nurse is caring for a client who has chronic kidney disease. The nurse should identify which of the following laboratory values as an indication for hemodialysis?

• A. Glomerular filtration rate of 14 mL/min
• B. BUN 16 mg/dL
• C. Serum magnesium 1.8 mg/dL
• D. Serum phosphorus 4.0 mg/dL

Correct answer: A

Rationale: A glomerular filtration rate (GFR) of 14 mL/min indicates severely impaired kidney function, often necessitating hemodialysis to support renal function and manage fluid and electrolyte balance. A BUN level of 16 mg/dL falls within the normal range (7-20 mg/dL) and does not specifically indicate the need for hemodialysis. Serum magnesium at 1.8 mg/dL and serum phosphorus at 4.0 mg/dL are also within normal ranges and do not typically prompt the immediate need for hemodialysis in chronic kidney disease.

4. A nurse is assessing four clients for fluid balance. Which of the following clients is exhibiting manifestations of dehydration?

• A. A client who has a urine specific gravity of 1.010.
• B. A client who has a weight gain of 2.2 kg (2 lb) in 24 hr.
• C. A client who has a hematocrit of 45%.
• D. A client who has a temperature of 39°C (102°F).

Correct answer: D

Rationale: The correct answer is D because an elevated temperature is a common manifestation of dehydration. Choices A, B, and C are not indicative of dehydration. A urine specific gravity of 1.010 is within normal range, weight gain suggests fluid overload, and a hematocrit of 45% is also within normal limits and not specifically related to dehydration.

5. A nurse in a mental health facility receives a change-of-shift report on four clients. Which of the following clients should the nurse assess first?

• A. Client placed in restraints for aggressive behavior
• B. A new client with a history of a 4.5 kg weight loss in the past two months
• C. Client who received a PRN dose of haloperidol 2 hours ago for increased anxiety
• D. Client who will be receiving his first ECT treatment today

Correct answer: A

Rationale: A client in restraints due to aggressive behavior needs immediate assessment to ensure safety and well-being. The nurse should assess this client first to address any potential risks, such as circulation issues, skin integrity problems, and ongoing agitation. Choices B, C, and D do not present immediate safety concerns that require urgent assessment compared to a client restrained for aggressive behavior.

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