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 client presenting with complaints of not feeling well is seen in a clinic. The client is taking several medications for the control of heart disease and hypertension, including a beta-blocker, digoxin (Lanoxin), and a diuretic. A tentative diagnosis of digoxin toxicity is made. Which of the following assessment data would support this diagnosis?

• A. Dyspnea, edema, and palpitations
• B. Chest pain, hypotension, and paresthesia
• C. Double vision, loss of appetite, and nausea
• D. Constipation, dry mouth, and sleep disorder

Correct answer: C

Rationale: The correct answer is C. Double vision, loss of appetite, and nausea are classic signs of digoxin toxicity. Other signs may include bradycardia, visual disturbances, and confusion. These symptoms are indicators that the client may be experiencing adverse effects due to elevated levels of digoxin in the system, requiring immediate medical attention to prevent serious complications.

3. The client has begun medication therapy with pancrelipase (Pancrease MT). The nurse evaluates that the medication is having the optimal intended benefit if which effect is observed?

• A. Weight loss
• B. Relief of heartburn
• C. Reduction of steatorrhea
• D. Absence of abdominal pain

Correct answer: C

Rationale: Pancrelipase (Pancrease MT) is a pancreatic enzyme replacement therapy used to aid digestion in clients with pancreatic insufficiency. One of the key goals of pancrelipase therapy is to reduce the amount of undigested fat in the stool, known as steatorrhea. Therefore, the nurse should evaluate the effectiveness of pancrelipase by looking for a reduction in steatorrhea, indicating improved digestion and absorption of fats.

4. The client who chronically uses nonsteroidal anti-inflammatory drugs (NSAIDs) has been taking misoprostol (Cytotec). The nurse determines that the medication is having the intended therapeutic effect if which of the following is noted?

• A. Resolved diarrhea
• B. Relief of epigastric pain
• C. Decreased platelet count
• D. Decreased white blood cell count

Correct answer: B

Rationale: Misoprostol is a gastric protectant administered to clients using NSAIDs to prevent gastric mucosal injury. Relief of epigastric pain signifies the medication's therapeutic effect as it indicates a reduction in gastrointestinal symptoms associated with NSAID use.

5. A client with hypertension is prescribed lisinopril (Zestril). Which instruction should the nurse include in the teaching plan?

• A. Avoid foods high in potassium.
• B. Avoid taking the medication with grapefruit juice.
• C. Monitor blood pressure regularly.
• D. Report any swelling of the lips or face.

Correct answer: D

Rationale: The correct instruction for the nurse to include in the teaching plan is to 'Report any swelling of the lips or face.' Lisinopril (Zestril) can cause angioedema, which is swelling of the lips or face. This is a serious side effect that should be reported immediately. Clients do not need to avoid potassium-rich foods unless instructed by their healthcare provider, should avoid taking the medication with grapefruit juice, and should monitor their blood pressure regularly, not just weekly.

Similar Questions