Nursing Elites

1. A client is receiving morphine sulfate subcutaneously for pain. Because morphine sulfate has been prescribed for this client, which nursing action would be included in the plan of care?

• A. Encourage fluid intake.
• B. Monitor the client's temperature.
• C. Maintain the client in a supine position.
• D. Encourage the client to cough and deep breathe.

Correct answer: D

Rationale: Morphine sulfate suppresses the cough reflex, which can lead to the retention of secretions in the lungs. Encouraging the client to cough and deep breathe helps prevent pneumonia by clearing the airways of any accumulated secretions. This intervention is crucial in clients receiving morphine sulfate to maintain optimal respiratory function.

2. A client is prescribed phenytoin (Dilantin) for seizure control. Which statement by the client indicates an understanding of the medication?

• A. I should brush and floss my teeth regularly.
• B. I should take the medication with antacids.
• C. I can stop taking the medication once my seizures are controlled.
• D. I should avoid drinking milk while taking this medication.

Correct answer: A

Rationale: The correct statement is 'I should brush and floss my teeth regularly.' Phenytoin (Dilantin) can cause gingival hyperplasia, so maintaining good oral hygiene is essential. Taking the medication with antacids can affect its absorption, so it should not be done. It is crucial not to stop taking the medication abruptly, even if seizures are controlled. There is no specific requirement to avoid milk while taking phenytoin (Dilantin).

3. A client has been prescribed cyclosporine (Sandimmune). Which food item should the client avoid based on the medication's interaction?

• A. Red meats
• B. Orange juice
• C. Grapefruit juice
• D. Green, leafy vegetables

Correct answer: C

Rationale: Grapefruit juice should be avoided when taking cyclosporine because it inhibits the metabolism of the medication, leading to increased blood levels and a higher risk of toxicity. It is important for the client to follow this dietary instruction to ensure the safe and effective use of cyclosporine.

4. 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.

5. A health care provider (HCP) writes a prescription for digoxin (Lanoxin), 0.25 mg daily. The nurse teaches the client about the medication and tells the client that it is important to:

• A. Count the radial and carotid pulses every morning.
• B. Check the blood pressure every morning and evening.
• C. Stop taking the medication if the pulse is higher than 100 beats per minute.
• D. Withhold the medication and call the HCP if the pulse is less than 60 beats per minute.

Correct answer: D

Rationale: When taking digoxin, monitoring the pulse rate is essential due to its potential effects on heart rate. Digoxin can lead to bradycardia, where the pulse rate drops significantly. Withholding the medication and promptly contacting the healthcare provider if the pulse falls below 60 beats per minute is crucial to prevent severe complications and ensure appropriate management. Choices A, B, and C are incorrect because counting radial and carotid pulses, checking blood pressure, or stopping the medication based on a pulse rate higher than 100 beats per minute are not the primary monitoring parameters for a client taking digoxin.

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