a nurse is caring for a client with a prescription for duloxetine which of the following should the nurse monitor
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 B

1. A nurse is caring for a client with a prescription for duloxetine. Which of the following should the nurse monitor?

Correct answer: A

Rationale: The correct answer is A) Liver function. Duloxetine can affect liver function, making it crucial for the nurse to monitor liver function tests. Monitoring serum electrolytes (choice B), blood glucose (choice C), or potassium levels (choice D) is not directly associated with duloxetine use and would not be the priority in this case.

2. A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse to take is to initiate seizure precautions for the client. Severe preeclampsia increases the risk of seizures (eclampsia), making it crucial to prioritize the safety of the client. Restricting protein intake (Choice A) is not the priority in this situation as seizure prevention takes precedence. While maintaining hydration is essential, starting an infusion of 0.9% sodium chloride (Choice C) is not the initial action needed for seizure prevention. Encouraging the client to ambulate (Choice D) may not be safe or appropriate considering the severity of preeclampsia and the risk of seizures.

3. A nurse is caring for a client prescribed sildenafil for erectile dysfunction. Which of the following should the nurse monitor?

Correct answer: A

Rationale: The correct answer is A: Blood pressure. Sildenafil, a medication for erectile dysfunction, can cause changes in blood pressure. The nurse should monitor for hypotension as a potential side effect. Monitoring heart rate (choice B) is not a priority when administering sildenafil unless there are pre-existing heart conditions. Temperature (choice C) and respiratory rate (choice D) are typically not directly affected by sildenafil administration, making them less relevant for monitoring in this case.

4. A client is receiving enoxaparin for the prevention of DVT. Which of the following is an appropriate action by the nurse?

Correct answer: C

Rationale: The correct answer is to inject enoxaparin into the lateral abdominal wall for subcutaneous absorption. This site is commonly used for administering this type of medication. Expelling air bubbles from the syringe is not necessary and may result in a reduced dose being administered. Massaging the injection site is not recommended as it can lead to bruising or irritation. Administering an NSAID for injection site discomfort is not indicated as discomfort at the injection site is usually minimal and self-limiting.

5. A nurse is caring for a client with a stage 2 pressure ulcer. Define the characteristics of the ulcer.

Correct answer: C

Rationale: The correct answer is C. Stage 2 ulcers involve partial-thickness skin loss with visible and superficial damage, which may appear as an abrasion, blister, or shallow crater. Choice A describes a Stage 1 pressure ulcer characterized by intact skin with nonblanchable redness. Choice B describes a Stage 3 pressure ulcer with full-thickness tissue loss and damage to the subcutaneous tissue. Choice D is indicative of a Stage 4 pressure ulcer, involving full-thickness tissue loss with damage extending to muscle or bone.

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