Nursing Elites

1. A client is receiving meperidine (Demerol) for pain management. Which assessment finding requires immediate action?

• A. Constipation
• B. Drowsiness
• C. Respiratory rate of 10 breaths per minute
• D. Nausea

Correct answer: C

Rationale: A respiratory rate of 10 breaths per minute indicates respiratory depression, a severe side effect of meperidine (Demerol) that necessitates immediate intervention to prevent further complications. Constipation, drowsiness, and nausea are common but less urgent side effects that do not pose an immediate life-threatening risk. Respiratory depression can lead to respiratory arrest and must be addressed promptly to ensure the client's safety and well-being.

2. A healthcare professional prepares to administer sodium polystyrene sulfonate (Kayexalate) to a client. Before administering the medication, the professional reviews the action of the medication and understands that it:

• A. Releases bicarbonate in exchange for primarily sodium ions
• B. Releases sodium ions in exchange for primarily potassium ions
• C. Releases potassium ions in exchange for primarily sodium ions
• D. Releases sodium ions in exchange for primarily bicarbonate ions

Correct answer: B

Rationale: Sodium polystyrene sulfonate, such as Kayexalate, is a cation exchange resin that functions by releasing sodium ions in exchange for primarily potassium ions. This medication is commonly used to treat hyperkalemia, a condition characterized by elevated levels of potassium in the blood.

3. A client is being cared for by a nurse due to severe back pain, and codeine sulfate has been prescribed. Which of the following should the nurse include in the plan of care while the client is taking this medication?

• A. Restrict fluid intake.
• B. Monitor bowel activity.
• C. Monitor for hypertension.
• D. Monitor peripheral pulses.

Correct answer: B

Rationale: When a client is prescribed codeine sulfate, it is essential to monitor bowel activity because this medication can lead to constipation. Therefore, monitoring bowel function is crucial to prevent or manage any potential gastrointestinal issues that may arise.

4. A client is prescribed nitroglycerin (Nitro-Dur) transdermal patch for angina. Which instruction should the nurse include in the client's teaching plan?

• A. Apply the patch to a hairless area of skin.
• B. Leave the patch on for 24 hours.
• C. Apply the patch at the same time each day.
• D. You can keep the patch on while taking a shower.

Correct answer: C

Rationale: The correct instruction for the nurse to include in the client's teaching plan is to apply the nitroglycerin (Nitro-Dur) transdermal patch at the same time each day. This consistency helps maintain steady blood levels of the medication. While it is important to apply the patch to a hairless area of the skin for proper absorption, it does not necessarily have to be left on for 24 hours; typically, it is worn for 12-14 hours to allow for a nitrate-free period and reduce tolerance. Additionally, the patch can generally be kept on while taking a shower, as water exposure does not typically affect its efficacy.

5. A client has been taking isoniazid (INH) for 2 months. The client complains to a nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing:

• A. Hypercalcemia
• B. Peripheral neuritis
• C. Small blood vessel spasm
• D. Impaired peripheral circulation

Correct answer: B

Rationale: The client's symptoms of numbness, paresthesias, and tingling in the extremities indicate peripheral neuritis, a common side effect of isoniazid (INH). This condition can be managed by supplementing with pyridoxine (vitamin B6) to minimize the symptoms.

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