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 with chronic renal failure is receiving ferrous sulfate (Feosol). The nurse monitors the client for which common side effect associated with this medication?

• A. Diarrhea
• B. Weakness
• C. Headache
• D. Constipation

Correct answer: D

Rationale: Constipation is a common side effect of iron supplements such as ferrous sulfate. Iron can cause constipation by slowing down the movement of the digestive system and hardening the stool. Patients should be advised to increase their fluid intake, dietary fiber, and physical activity to help alleviate this side effect. Diarrhea (Choice A) is not a common side effect associated with ferrous sulfate. Weakness (Choice B) and headache (Choice C) are not typically linked to this medication.

3. 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.

4. A client with hyperparathyroidism has a serum calcium level of 13 mg/dL. Which medication should be prepared to administer as prescribed to the client?

• A. Calcium chloride
• B. Calcium gluconate
• C. Calcitonin (Miacalcin)
• D. Large doses of vitamin D

Correct answer: C

Rationale: The normal serum calcium level ranges from 8.6 to 10.0 mg/dL. In hypercalcemia, as seen in this client, Calcitonin (Miacalcin) is used to decrease plasma calcium levels by inhibiting bone resorption. Calcium gluconate and calcium chloride are typically used for hypocalcemia, not hypercalcemia. Large doses of vitamin D should be avoided in hypercalcemia as they can exacerbate hypercalcemia by increasing calcium absorption from the intestines.

5. Glimepiride (Amaryl) is prescribed for a client with diabetes mellitus. A healthcare provider reinforces instructions for the client and advises them to avoid which of the following while taking this medication?

• A. Alcohol
• B. Organ meats
• C. Whole-grain cereals
• D. Carbonated beverages

Correct answer: A

Rationale: Alcohol should be avoided when taking glimepiride (Amaryl) because it can cause a disulfiram-like reaction and enhance the hypoglycemic effects of the medication. Consuming alcohol with glimepiride can lead to symptoms such as flushing, palpitations, nausea, and vomiting. Therefore, it is crucial for individuals on glimepiride therapy to steer clear of alcohol to prevent adverse reactions and maintain optimal medication efficacy.

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