Nursing Elites

1. A postoperative client has received a dose of naloxone hydrochloride for respiratory depression shortly after transfer to the nursing unit from the postanesthesia care unit. After administration of the medication, the nurse checks the client for:

• A. Pupillary changes
• B. Scattered lung wheezes
• C. Sudden increase in pain
• D. Sudden episodes of diarrhea

Correct answer: C

Rationale: Naloxone hydrochloride is an antidote to opioids and may be administered to postoperative clients to address respiratory depression. This medication can also reverse the effects of analgesics, potentially leading to a sudden increase in pain. Therefore, the nurse must assess the client for any unexpected rise in pain levels after naloxone administration. Choices A, B, and D are incorrect because pupillary changes, scattered lung wheezes, and sudden episodes of diarrhea are not typically associated with naloxone administration for respiratory depression.

2. Intravenous heparin therapy is prescribed for a client. While implementing this prescription, a nurse ensures that which of the following medications is available on the nursing unit?

• A. Protamine sulfate
• B. Potassium chloride
• C. Phytonadione (vitamin K)
• D. Aminocaproic acid (Amicar)

Correct answer: A

Rationale: Protamine sulfate is the antidote for heparin, working to reverse its effects in case of excessive bleeding. It should be readily available when administering heparin to manage any potential bleeding complications effectively. Potassium chloride is not the antidote for heparin and is typically used to correct low potassium levels. Phytonadione (vitamin K) is used to reverse the effects of warfarin, not heparin. Aminocaproic acid (Amicar) is used to treat or prevent excessive bleeding but is not the antidote for heparin.

3. A client with trigeminal neuralgia tells the nurse that acetaminophen (Tylenol) is taken on a frequent daily basis for relief of generalized discomfort. The nurse reviews the client's laboratory results and determines that which of the following indicates toxicity associated with the medication?

• A. Sodium of 140 mEq/L
• B. Prothrombin time of 12 seconds
• C. Platelet count of 400,000 cells/mm³
• D. A direct bilirubin level of 2 mg/dL

Correct answer: D

Rationale: A direct bilirubin level of 2 mg/dL indicates liver damage, which can be caused by an overdose of acetaminophen. Acetaminophen toxicity can lead to liver injury, manifesting as elevated bilirubin levels and other liver function test abnormalities.

4. A client has begun therapy with theophylline (Theo-24). The nurse tells the client to limit the intake of which of the following while taking this medication?

• A. Oranges and pineapple
• B. Coffee, cola, and chocolate
• C. Oysters, lobster, and shrimp
• D. Cottage cheese, cream cheese, and dairy creamers

Correct answer: B

Rationale: Theophylline is a xanthine bronchodilator. Xanthines are found in coffee, cola, and chocolate. These foods should be limited while taking theophylline to prevent potential drug interactions or adverse effects.

5. The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied:

• A. Immediately before swimming
• B. 15 minutes before exposure to the sun
• C. Immediately before exposure to the sun
• D. At least 30 minutes before exposure to the sun

Correct answer: D

Rationale: Chemical sunscreens are most effective when applied at least 30 minutes before exposure to the sun to allow them to penetrate the skin and provide optimal protection. Applying sunscreen immediately before swimming (Choice A) or immediately before exposure to the sun (Choice C) may not provide sufficient time for the sunscreen to be absorbed and offer proper protection. Applying sunscreen 15 minutes before sun exposure (Choice B) is also not ideal as it may not allow enough time for the sunscreen to work effectively. Therefore, the correct answer is to apply chemical sunscreen at least 30 minutes before exposure to the sun to ensure it can be absorbed and offer the intended protection. It is important to reapply sunscreen after swimming or sweating to maintain its effectiveness.

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