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. Which of the following is not a side effect associated with Prednisone toxicity?

• A. Cataracts
• B. Hypotension
• C. Psychosis
• D. Acne

Correct answer: B

Rationale: Prednisone toxicity is not typically associated with hypotension; instead, it can lead to hypertension. Cataracts, psychosis, and acne are known side effects of Prednisone toxicity.

3. A client has a new prescription for Verapamil to control hypertension. Which of the following instructions should the nurse include?

• A. Increase the amount of dietary fiber in the diet.
• B. Drink grapefruit juice daily to increase vitamin C intake.
• C. Decrease the amount of calcium in the diet.
• D. Withhold food for 1 hr after taking the medication.

Correct answer: A

Rationale: Increasing dietary fiber intake is essential when taking Verapamil to prevent constipation, a common adverse effect of this medication. Verapamil is a calcium channel blocker used to treat hypertension, and dietary fiber helps maintain bowel regularity and prevent constipation that may occur as a side effect of the medication.

4. A client is taking Furosemide for heart failure. Which of the following findings is a priority to report to the provider?

• A. Weight loss of 1 kg in 24 hours
• B. Blood pressure of 104/60 mm Hg
• C. Potassium level of 3.5 mEq/L
• D. Urine output of 200 mL in 8 hours

Correct answer: D

Rationale: A urine output of 200 mL in 8 hours indicates decreased kidney function and potential worsening heart failure. This finding should be reported promptly to the provider for further evaluation and management to prevent complications. Weight loss, while significant, may be expected with diuretic use. A blood pressure of 104/60 mm Hg is within normal range and can be managed. A potassium level of 3.5 mEq/L is slightly low but not an immediate concern.

5. A client with breast cancer is being taught by a nurse about the adverse effects of chemotherapy. Which of the following statements should the nurse include?

• A. You should use a soft-bristled toothbrush to prevent bleeding.
• B. You should avoid contact with individuals who recently received live virus vaccines.
• C. You should take aspirin for minor aches and pains.
• D. You should consume a diet low in protein to reduce the risk of renal damage.

Correct answer: A

Rationale: The nurse should instruct the client to use a soft-bristled toothbrush to prevent bleeding, which can occur due to chemotherapy-induced thrombocytopenia. Chemotherapy can decrease platelet counts, leading to an increased risk of bleeding. Using a soft-bristled toothbrush can help prevent gum bleeding and oral trauma. Choices B, C, and D are incorrect. Avoiding contact with individuals who recently received live virus vaccines is crucial to prevent infections in immunocompromised clients. Aspirin should be avoided due to its blood-thinning effects that can increase the risk of bleeding. A diet low in protein is not recommended as cancer clients often require adequate protein intake for healing and recovery.

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