Nursing Elites

1. A client is being monitored while receiving bethanechol chloride (Urecholine) for urinary retention. Which of the following indicates a therapeutic effect of this medication?

• A. Increased heart rate
• B. Increased peristalsis
• C. Passage of flatus
• D. Urinary output of 50 mL per hour

Correct answer: D

Rationale: Bethanechol chloride (Urecholine) is administered to stimulate the bladder and treat urinary retention. The therapeutic effect is indicated by an increased urinary output, as it demonstrates the medication's ability to prompt the bladder to empty. Increased heart rate and passage of flatus are unrelated to the therapeutic effects of bethanechol. Although bethanechol can increase peristalsis, the primary therapeutic goal is to address urinary retention.

2. The clinic nurse is performing an admission assessment on a client. The nurse notes that the client is taking azelaic acid (Azelex). Because of the medication prescription, the nurse would suspect that the client is being treated for:

• A. Acne
• B. Eczema
• C. Hair loss
• D. Herpes simplex

Correct answer: A

Rationale: Azelaic acid (Azelex) is a topical medication used to treat mild to moderate acne. It works by suppressing the growth of Propionibacterium acnes and decreasing the proliferation of keratinocytes in the skin. Therefore, if a client is prescribed azelaic acid, the nurse would suspect that the client is being treated for acne.

3. A client is receiving dietary instructions from a nurse regarding warfarin sodium (Coumadin) therapy. The nurse advises the client to avoid which food item?

• A. Grapes
• B. Spinach
• C. Watermelon
• D. Cottage cheese

Correct answer: B

Rationale: The correct answer is B: Spinach. Spinach is high in vitamin K, which antagonizes the effects of warfarin sodium, an anticoagulant medication. Clients taking warfarin should avoid consuming foods rich in vitamin K, like spinach, to maintain the medication's effectiveness. Grapes (choice A), watermelon (choice C), and cottage cheese (choice D) do not interfere with the effects of warfarin, so they are safe for the client to consume while on warfarin therapy.

4. A client has just taken a dose of trimethobenzamide (Tigan). The nurse plans to monitor this client for relief of:

• A. Heartburn
• B. Constipation
• C. Abdominal pain
• D. Nausea and vomiting

Correct answer: D

Rationale: The correct answer is D: Nausea and vomiting. Trimethobenzamide (Tigan) is an antiemetic medication used to treat nausea and vomiting. Therefore, the nurse would monitor the client for relief of nausea and vomiting after taking this medication.

5. A client is receiving an intravenous (IV) infusion of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site. The nurse notes redness and swelling at the site, along with a slowed infusion rate. What is the appropriate action for the nurse to take?

• A. Notify the healthcare provider.
• B. Administer pain medication to reduce discomfort.
• C. Apply ice and maintain the infusion rate as prescribed.
• D. Elevate the extremity of the IV site and slow the infusion rate.

Correct answer: A

Rationale: When a client complains of pain at the IV insertion site, and there are signs of extravasation such as redness and swelling, it is crucial to notify the healthcare provider immediately. Extravasation of antineoplastic medications can cause tissue damage, pain, and necrosis if they escape into surrounding tissues. Prompt action is necessary to prevent further complications and ensure appropriate management of the situation. Administering pain medication, applying ice, or elevating the extremity are not appropriate actions in cases of suspected extravasation. These actions do not address the underlying issue of potential tissue damage and necrosis that can occur due to the leakage of antineoplastic medication.

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