Nursing Elites

1. A nurse is providing discharge teaching for a client newly prescribed methadone. Which statement indicates a need for further teaching?

• A. I understand methadone slows my breathing.
• B. I understand methadone may cause me to have trouble sleeping.
• C. I will avoid alcohol while taking this medication.
• D. I’ll change positions slowly to prevent dizziness.

Correct answer: B

Rationale: The correct answer is B. Trouble sleeping is not a typical side effect of methadone; the nurse should clarify this misunderstanding. Choices A, C, and D are all correct statements regarding methadone. Methadone can indeed slow breathing, so it is important for the client to be aware of this effect. Avoiding alcohol while taking methadone is crucial due to the increased risk of central nervous system depression when alcohol is combined with methadone. Additionally, changing positions slowly can help prevent dizziness, which can be a side effect of methadone.

2. A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the umbilical cord protruding through the cervix. Which of the following actions should the nurse take?

• A. Administer oxytocin to the client via intravenous infusion
• B. Apply oxygen at 2 L/min via nasal cannula
• C. Prepare for insertion of an intrauterine pressure catheter
• D. Assist the client into the knee-chest position

Correct answer: D

Rationale: The nurse should assist the client into the knee-chest position to relieve pressure on the umbilical cord. This position helps to prevent cord compression and improves fetal oxygenation. Administering oxytocin (Choice A) could worsen the situation by increasing contractions and potentially compressing the umbilical cord. Applying oxygen (Choice B) is not the priority in this emergency situation. Preparing for insertion of an intrauterine pressure catheter (Choice C) is not appropriate as the immediate concern is relieving pressure on the umbilical cord.

3. A client with heart failure and a new prescription for furosemide is receiving teaching from a nurse. Which of the following instructions should the nurse include?

• A. Avoid foods high in magnesium
• B. Take furosemide with food
• C. Eat foods that are rich in potassium
• D. Expect a decrease in blood pressure

Correct answer: C

Rationale: The correct instruction the nurse should include is to advise the client to eat foods that are rich in potassium. Furosemide is a loop diuretic that can cause the loss of potassium, leading to hypokalemia. Eating foods high in potassium can help prevent this electrolyte imbalance. Choice A is incorrect because furosemide does not directly interact with magnesium. Choice B is incorrect because furosemide is usually taken in the morning to prevent nighttime diuresis. Choice D is incorrect because furosemide is a diuretic that typically leads to a decrease in blood pressure rather than an increase.

4. A client has a prescription for sertraline to treat depression. Which of the following statements by the client indicates an understanding of the medication treatment plan?

• A. I will start feeling better immediately after starting the medication
• B. I can expect to urinate frequently while on this medication
• C. I understand I may experience difficulty sleeping on this medication
• D. I should decrease my sodium intake while on this medication

Correct answer: C

Rationale: The correct answer is C. Difficulty sleeping is a common side effect of sertraline, an SSRI used to treat depression. Clients should be educated to expect this, especially during the early stages of treatment. Choice A is incorrect because sertraline may take a few weeks to show its full effect. Choice B is incorrect as increased urination is not a common side effect of sertraline. Choice D is unrelated to the side effects or management of sertraline.

5. A nurse is planning to administer an injection of morphine to a client. Which of the following actions should the nurse take to ensure client safety?

• A. Instruct the client to take a deep breath during administration.
• B. Administer the medication over 30 seconds.
• C. Verify the client’s pain level.
• D. Have naloxone available in case of respiratory depression.

Correct answer: D

Rationale: The correct answer is to have naloxone available in case of respiratory depression. Morphine is an opioid that can lead to respiratory depression, especially in higher doses. Naloxone is the antidote for opioid overdose and should be readily accessible when administering morphine to reverse respiratory depression if it occurs. Instructing the client to take a deep breath during administration (choice A) is not directly related to ensuring safety in this scenario. Administering the medication over 30 seconds (choice B) may help with the comfort of the client but does not address the potential risk of respiratory depression. Verifying the client's pain level (choice C) is important but not the primary action to ensure safety when administering morphine.

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