Nursing Elites

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

• A. Take the medication at bedtime.
• B. Monitor your blood pressure regularly.
• C. Expect to have increased energy levels.
• D. Avoid foods high in potassium.

Correct answer: B

Rationale: The correct answer is to monitor blood pressure regularly. Hydralazine is an antihypertensive medication that helps lower blood pressure. Monitoring blood pressure regularly is essential to ensure it remains within the target range and to assess the effectiveness of the medication. Choice A is incorrect because the timing of taking Hydralazine is usually not specified as bedtime. Choice C is incorrect because increased energy levels are not an expected effect of Hydralazine. Choice D is incorrect because Hydralazine does not interact with potassium in the same way as other medications like potassium-sparing diuretics.

2. 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.

3. A client has a prescription for ceftriaxone. Which of the following information should the nurse include in the teaching?

• A. You may develop a cough while taking this medication.
• B. You should stop taking this medication if you develop a rash.
• C. This medication cannot be given orally.
• D. This medication may cause your urine to turn yellow.

Correct answer: B

Rationale: The correct answer is B. A rash can indicate an allergic reaction to ceftriaxone, which should be reported to the provider. It is crucial to instruct the client to discontinue the medication and seek medical attention if a rash develops to prevent potential serious adverse effects. Choices A, C, and D are incorrect because cough is not a common side effect of ceftriaxone, ceftriaxone is typically administered parenterally, and a yellow discoloration of urine is a harmless side effect due to the color of the medication itself, respectively.

4. What is the antidote for Heparin?

• A. Protamine sulfate
• B. Narcan
• C. Romazicon
• D. Naloxone

Correct answer: A

Rationale: The correct answer is A: Protamine sulfate. Heparin is an anticoagulant medication used to prevent blood clots. In cases of overdose or excessive bleeding due to Heparin, protamine sulfate is administered as the specific antidote. Protamine sulfate works by neutralizing Heparin's anticoagulant activity. Choices B, C, and D are incorrect. Narcan (Naloxone) is used to reverse opioid overdose, Romazicon (Flumazenil) is used to reverse benzodiazepine overdose, and Naloxone is also used to reverse opioid overdose but is not the antidote for Heparin.

5. A healthcare professional is preparing to administer a transfusion of a unit of packed red blood cells (PRBCs) for a client who has severe anemia. Which of the following interventions will prevent an acute hemolytic reaction?

• A. Ensure that the client has a patent IV line before obtaining the blood product from the refrigerator.
• B. Obtain help from another healthcare professional to confirm the correct client and blood product.
• C. Take a complete set of vital signs before beginning the transfusion and periodically during the transfusion.
• D. Stay with the client for the first 15 to 30 minutes of the transfusion.

Correct answer: B

Rationale: Obtaining help from another healthcare professional to confirm the correct client and blood product is crucial in preventing an acute hemolytic reaction during a blood transfusion. This reaction occurs due to ABO or Rh incompatibility. Verifying the correct client and blood product reduces the risk of administering the wrong blood type, which could lead to a life-threatening reaction. Checking for patency of the IV line (Choice A) is important but does not directly prevent an acute hemolytic reaction. Monitoring vital signs (Choice C) is essential for detecting transfusion reactions but does not prevent them. Staying with the client (Choice D) is important for early recognition of adverse reactions but does not address the root cause of preventing an acute hemolytic reaction.

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