Nursing Elites

1. A nurse is supervising an LPN who is providing care to a patient who is postoperative. Which of the following statements by the patient requires the nurse to follow up with the LPN?

• A. “I am experiencing some pain, but it’s tolerable.”
• B. “The nurse checked my vital signs earlier.”
• C. “I have not received any of my medications today.”
• D. “I am scheduled for therapy later today.”

Correct answer: C

Rationale: If the patient states they have not received any medications, it requires immediate follow-up to prevent missed doses and complications. The other options do not pose an immediate risk to the patient. Option A indicates pain but is tolerable, which is a common postoperative experience. Option B states that vital signs were checked, indicating ongoing monitoring. Option D mentions therapy, which is a scheduled activity and not an urgent concern regarding medication administration.

2. A client in labor has an epidural for pain control. Which of the following clinical manifestations is an adverse effect of epidural anesthesia?

• A. Polyuria
• B. Hypertension
• C. Pruritus
• D. Dry mouth

Correct answer: C

Rationale: Pruritus is a common adverse effect of epidural anesthesia, often due to the opioids administered with the epidural. It presents as itching on the skin and can cause significant discomfort to the client. Polyuria (excessive urination) and dry mouth are not typical adverse effects of epidural anesthesia. Hypertension is not commonly associated with epidural anesthesia; in fact, hypotension is a more frequent complication due to sympathetic blockade. Therefore, the correct answer is pruritus (choice C), as it is a known adverse effect of epidural anesthesia.

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

• A. Liver function
• B. Serum electrolytes
• C. Blood glucose
• D. Potassium levels

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.

4. A nurse is caring for a client prescribed hydromorphone for severe pain. The client's respiratory rate has decreased from 16 breaths per minute to 6. Which of the following medications should the nurse prepare to administer?

• A. Naloxone
• B. Flumazenil
• C. Activated charcoal
• D. Aluminum hydroxide

Correct answer: A

Rationale: Naloxone is the correct answer. Naloxone is the antidote for opioid overdose, including hydromorphone. Opioids can cause respiratory depression, and a significant decrease in respiratory rate from 16 to 6 breaths per minute indicates respiratory compromise. Naloxone should be administered promptly to reverse the effects of the opioid and restore normal respiratory function. Flumazenil (Choice B) is used to reverse the effects of benzodiazepines, not opioids. Activated charcoal (Choice C) is used for gastrointestinal decontamination in cases of overdose with certain substances, but it is not the appropriate intervention for opioid-induced respiratory depression. Aluminum hydroxide (Choice D) is an antacid and has no role in managing opioid overdose or respiratory depression.

5. What is the nurse's next action after a laboring client's membranes have just ruptured?

• A. Assess fetal heart rate pattern
• B. Monitor uterine contractions
• C. Administer oxygen
• D. Prepare for delivery

Correct answer: A

Rationale: After a laboring client's membranes have ruptured, the nurse's immediate priority is to assess the fetal heart rate pattern. This assessment is crucial to ensure the fetus is not in distress, especially to rule out umbilical cord compression that could affect blood flow to the fetus. While monitoring uterine contractions is important, assessing the fetal heart rate takes precedence in this situation as it directly reflects the fetus's well-being. Administering oxygen may be necessary later depending on the fetal status, and preparing for delivery should only occur if the assessment indicates fetal distress or other complications. Therefore, the correct next action for the nurse is to assess the fetal heart rate pattern.

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