Nursing Elites

1. A client in labor is receiving IV Opioid analgesics. Which of the following actions should the nurse take?

• A. Instruct the client to self-ambulate every 2 hours.
• B. Offer oral hygiene every 2 hours.
• C. Anticipate medication administration 2 hours prior to delivery.
• D. Monitor fetal heart rate every 2 hours.

Correct answer: B

Rationale: Offering oral hygiene every 2 hours is essential for a client receiving opioid analgesics to prevent dry mouth, nausea, and vomiting, which are common adverse effects associated with opioid use. This intervention promotes comfort and enhances the client's well-being during labor. Instructing the client to self-ambulate every 2 hours is not appropriate for a client in labor receiving opioid analgesics, as it may be challenging and unnecessary during this time. Anticipating medication administration 2 hours prior to delivery is not necessary as the timing of medication administration should be based on the client's pain level and the duration of action of the opioid. Monitoring fetal heart rate every 2 hours is important during labor, but the priority in this case is to address the client's comfort and well-being by offering oral hygiene.

2. A healthcare professional is preparing to administer heparin 15,000 units subcutaneously every 12 hours. The available heparin injection is 20,000 units/mL. How many milliliters should the healthcare professional administer per dose?

• A. 0.8 mL
• B. 0.75 mL
• C. 0.5 mL
• D. 1 mL

Correct answer: A

Rationale: To calculate the volume to administer, use the formula: Desired dose / Concentration = Volume to administer. In this case, (15,000 units / 20,000 units/mL) = 0.75 mL. Since the volume needs to be rounded up to the nearest tenth, the correct answer is 0.8 mL. Choice B (0.75 mL) is incorrect because it does not account for rounding up the volume. Choices C (0.5 mL) and D (1 mL) are incorrect as they do not reflect the precise calculation based on the given concentration and desired dose.

3. When teaching a client with a new prescription for warfarin, which statement should the nurse include?

• A. Avoid using a soft toothbrush.
• B. Avoid foods high in vitamin K.
• C. Report any signs of bleeding to your provider.
• D. Use an electric shaver for shaving.

Correct answer: C

Rationale: The correct statement the nurse should include when teaching a client with a new prescription for warfarin is to report any signs of bleeding to their provider. Bleeding can indicate excessive anticoagulation, a potential side effect of warfarin therapy that needs prompt medical attention. Choices A, B, and D are incorrect because while oral hygiene measures, dietary considerations, and skin care are important, they are not the priority when teaching a client about warfarin therapy. Monitoring for and reporting signs of bleeding is crucial due to the anticoagulant effects of warfarin.

4. A client has a new prescription for Prednisone. Which of the following laboratory values should the nurse monitor?

• A. Serum potassium
• B. Serum calcium
• C. Serum sodium
• D. Serum glucose

Correct answer: D

Rationale: The correct answer is D, Serum glucose. Prednisone is a corticosteroid that can lead to hyperglycemia. Monitoring serum glucose levels is essential to assess for elevated blood sugar levels. Choices A, B, and C are incorrect as Prednisone does not directly affect potassium, calcium, or sodium levels.

5. A client has a new prescription for Beclomethasone. Which of the following instructions should the nurse include in the teaching?

• A. Take the medication with meals.
• B. Increase your intake of calcium-rich foods.
• C. Rinse your mouth after each use.
• D. Limit fluid intake while taking this medication.

Correct answer: C

Rationale: The correct answer is C: 'Rinse your mouth after each use.' Beclomethasone can cause oral candidiasis (thrush) as an adverse effect. Rinsing the mouth after each use helps reduce the risk of developing thrush by removing any residue of the medication from the mouth, which can promote fungal growth. Choices A, B, and D are incorrect. Taking the medication with meals, increasing calcium-rich foods intake, or limiting fluid intake are not specific instructions related to minimizing the side effect of oral candidiasis associated with Beclomethasone.

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