Nursing Elites

1. A client is receiving magnesium sulfate for the management of preeclampsia. Which of the following client assessments should the nurse monitor to prevent complications of therapy?

• A. Bowel sounds
• B. Deep tendon reflexes
• C. Oxygen saturation
• D. Fluid balance

Correct answer: B

Rationale: The correct answer is deep tendon reflexes. Monitoring deep tendon reflexes is crucial to assess for magnesium toxicity during therapy for preeclampsia. Magnesium sulfate can lead to neuromuscular blockade, reflected by decreased or absent deep tendon reflexes. Assessing bowel sounds (choice A) is important for gastrointestinal function but is not directly related to magnesium sulfate therapy. Oxygen saturation (choice C) is vital for respiratory status but is not specifically linked to magnesium sulfate administration. Fluid balance (choice D) is essential but does not directly correlate with monitoring for complications of magnesium sulfate therapy in the context of preeclampsia.

2. A nurse is preparing to administer nitroglycerin ointment to a client. Which of the following actions should the nurse take?

• A. Apply the ointment to the client's hairless chest
• B. Rub the ointment gently into the skin
• C. Cover the applied ointment with a transparent dressing
• D. Massage the ointment into the skin

Correct answer: A

Rationale: The correct action is to apply the nitroglycerin ointment to a hairless area of the client's chest, back, or upper arms. This allows for better absorption of the medication. Choice B is incorrect because rubbing the ointment gently into the skin may be appropriate, but the primary action is to ensure application on a hairless area. Choice C is incorrect as covering the ointment with a transparent dressing is not a standard practice for nitroglycerin ointment administration. Choice D is incorrect because massaging the ointment into the skin is not recommended, as it can alter absorption rates.

3. Disulfiram is taken by a client daily for abstinence maintenance. What is an adverse effect of this therapy?

• A. Hepatotoxicity
• B. Wernicke's aphasia
• C. Suicidal ideations
• D. Diarrhea

Correct answer: A

Rationale: The correct answer is A: Hepatotoxicity. Disulfiram is known to cause hepatotoxicity as a severe adverse effect. This occurs due to the inhibition of aldehyde dehydrogenase, leading to the accumulation of acetaldehyde when alcohol is consumed. Wernicke's aphasia (Choice B) is a language disorder unrelated to disulfiram therapy. Suicidal ideations (Choice C) may be associated with certain medications, but it is not a common adverse effect of disulfiram. Diarrhea (Choice D) is not a typical adverse effect of disulfiram.

4. A nurse is administering metformin to a client with type 2 diabetes. Which of the following adverse effects should the nurse monitor for in this client?

• A. Diarrhea
• B. Hyperglycemia
• C. Hypoglycemia
• D. Lactic acidosis

Correct answer: D

Rationale: The correct answer is D, Lactic acidosis. Lactic acidosis is a rare but serious adverse effect of metformin use. Metformin is not known to cause hyperglycemia or hypoglycemia. Diarrhea is a common gastrointestinal side effect of metformin but is not as serious as lactic acidosis, which requires immediate medical attention.

5. A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL. How many mL should the nurse administer per dose?

• A. 0.2 mL
• B. 0.4 mL
• C. 0.6 mL
• D. 0.8 mL

Correct answer: A

Rationale: The nurse should administer 0.2 mL of morphine sulfate. To calculate this, divide the desired dose (2 mg) by the concentration of the available solution (10 mg/mL). 2 mg / 10 mg/mL = 0.2 mL. Therefore, the nurse should administer 0.2 mL of morphine sulfate. Choices B, C, and D are incorrect as they do not reflect the accurate calculation based on the provided concentration and desired dose.

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