Nursing Elites

1. A client is receiving spironolactone. Which of the following findings should the nurse report to the provider?

• A. Serum Sodium 144 mEq/L
• B. Urine output 120 mL in 4 hrs
• C. Serum Potassium 5.2 mEq/L
• D. Blood Pressure 140/90 mmHg

Correct answer: C

Rationale: A serum potassium level of 5.2 mEq/L indicates hyperkalemia. Spironolactone is a potassium-sparing diuretic that can lead to potassium retention. The nurse should notify the provider and withhold the medication to prevent further elevation of potassium levels, which can result in serious cardiac complications. The other findings (Serum Sodium 144 mEq/L, Urine output 120 mL in 4 hrs, and Blood Pressure 140/90 mmHg) are within normal ranges and not directly related to spironolactone therapy.

2. A client has a new prescription for Digoxin. Which of the following findings should the nurse identify as a potential sign of Digoxin toxicity?

• A. Nausea
• B. Dry mouth
• C. Hypoglycemia
• D. Tinnitus

Correct answer: A

Rationale: Nausea is a potential sign of Digoxin toxicity. Other signs of Digoxin toxicity include vomiting, visual disturbances, and confusion. Nausea can be an early indicator of toxicity and should be closely monitored by the nurse. Dry mouth and hypoglycemia are not typically associated with Digoxin toxicity. Tinnitus is more commonly associated with medications like aspirin or loop diuretics, not Digoxin.

3. When administering IV Acyclovir to a client with Varicella, what action should the nurse take?

• A. Administer a stool softener
• B. Decrease fluid intake following infusion
• C. Infuse Acyclovir over 1 hr
• D. Monitor for hypotension

Correct answer: C

Rationale: When administering IV Acyclovir to a client with Varicella, the nurse should infuse the medication over at least 1 hour to prevent nephrotoxicity. Rapid infusion can lead to adverse effects such as renal damage. Therefore, it is crucial to follow the recommended infusion rate to ensure the client's safety and well-being. Choice A is incorrect as stool softeners are not indicated in this situation. Choice B is incorrect because fluid intake should be maintained or increased to prevent dehydration and support kidney function. Choice D is incorrect as monitoring for hypotension is not specifically related to the administration of IV Acyclovir in Varicella.

4. A client has a prescription for Clindamycin. Which of the following instructions should the nurse include?

• A. Take the medication with a full glass of water.
• B. Avoid taking the medication with food.
• C. Discontinue the medication if diarrhea occurs.
• D. Expect to have increased appetite while taking this medication.

Correct answer: A

Rationale: The correct instruction for a client taking Clindamycin is to take the medication with a full glass of water. Clindamycin can cause esophageal irritation, so taking it with a full glass of water helps minimize this risk. Avoiding taking the medication with food is not necessary. If diarrhea occurs, clients should not discontinue the medication without consulting their healthcare provider. Clindamycin is not known to cause increased appetite.

5. A healthcare provider is preparing to administer an Opioid agonist to a client who has acute pain. Which of the following complications should the healthcare provider monitor?

• A. Urinary retention
• B. Tachypnea
• C. Hypertension
• D. Irritating cough

Correct answer: A

Rationale: The correct answer is urinary retention. Opioid agonists like morphine can suppress the sensation of a full bladder, leading to urinary retention. Monitoring for this complication is crucial to prevent bladder distention and related issues. Choices B, C, and D are incorrect. Tachypnea (increased respiratory rate), hypertension (high blood pressure), and irritating cough are not typically associated with opioid agonist administration for pain management.

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