Nursing Elites

1. A client receives a local anesthetic of Lidocaine during the repair of a skin laceration. For which of the following adverse reactions should the nurse monitor the client?

• A. Seizures
• B. Tachycardia
• C. Hypertension
• D. Fever

Correct answer: A

Rationale: Seizures are a potential adverse reaction to local anesthetics like Lidocaine. Lidocaine can affect the central nervous system and, in some cases, lead to seizure activity. Therefore, it is important for the nurse to monitor the client for any signs of seizures during and after the administration of Lidocaine.

2. A client has a new prescription for Warfarin for atrial fibrillation. Which of the following findings should the nurse report to the provider immediately?

• A. INR of 4.0
• B. Potassium level of 4.5 mEq/L
• C. Sodium level of 140 mEq/L
• D. Creatinine level of 1.0 mg/dL

Correct answer: A

Rationale: An INR of 4.0 is above the therapeutic range for a client on Warfarin, indicating an increased risk of bleeding. This finding requires immediate reporting to the provider for appropriate intervention to prevent complications associated with excessive anticoagulation. Potassium, sodium, and creatinine levels are within normal ranges and are not directly related to the risk of bleeding in a client on Warfarin therapy.

3. A nurse is caring for a client who has a new prescription for Metformin. Which of the following instructions should the nurse include?

• A. Take this medication with food.
• B. Avoid eating foods high in potassium.
• C. Take this medication at bedtime.
• D. Take this medication every other day.

Correct answer: A

Rationale: The correct instruction for a client prescribed Metformin is to take the medication with food. Taking Metformin with meals helps reduce gastrointestinal side effects and ensures better absorption. Choice B, to avoid foods high in potassium, is not directly related to Metformin. Choice C, taking the medication at bedtime, is not a standard instruction for Metformin. Choice D, taking the medication every other day, is incorrect as Metformin is typically taken daily as prescribed.

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 is starting a new prescription for furosemide. Which of the following instructions should the nurse include?

• A. Weigh yourself daily.
• B. Limit sodium intake.
• C. Increase potassium intake.
• D. Avoid potassium-rich foods.

Correct answer: A

Rationale: The correct instruction to include when starting furosemide is to weigh yourself daily. Daily weighing helps monitor for fluid loss or retention, which is crucial when taking a diuretic like furosemide. Choices B, C, and D are incorrect because although monitoring sodium intake and potassium levels are important when taking furosemide, the most immediate and direct way to assess the medication's effectiveness and the body's response is through daily weight monitoring.

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