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. Rifabutin (Mycobutin) is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. The nurse monitors for which side effects of the medication? Select one that doesn't apply.

• A. Signs of hepatitis
• B. Flu-like syndrome
• C. Low neutrophil count
• D. Vitamin B6 deficiency

Correct answer: D

Rationale: Rifabutin is known to cause side effects such as hepatitis, flu-like syndrome, low neutrophil count, and ocular pain or blurred vision. Vitamin B6 deficiency is not associated with rifabutin but is a side effect of isoniazid (INH). Therefore, the nurse should not monitor for Vitamin B6 deficiency when administering rifabutin.

3. A client is being monitored while receiving bethanechol chloride (Urecholine) for urinary retention. Which of the following indicates a therapeutic effect of this medication?

• A. Increased heart rate
• B. Increased peristalsis
• C. Passage of flatus
• D. Urinary output of 50 mL per hour

Correct answer: D

Rationale: Bethanechol chloride (Urecholine) is administered to stimulate the bladder and treat urinary retention. The therapeutic effect is indicated by an increased urinary output, as it demonstrates the medication's ability to prompt the bladder to empty. Increased heart rate and passage of flatus are unrelated to the therapeutic effects of bethanechol. Although bethanechol can increase peristalsis, the primary therapeutic goal is to address urinary retention.

4. A client with angina pectoris is experiencing chest pain that radiates down the left arm. The nurse administers a sublingual nitroglycerin tablet to the client. The client's pain is unrelieved, and the nurse determines that the client needs another nitroglycerin tablet. Which of the following vital signs is most important for the nurse to check before administering the medication?

• A. Temperature
• B. Respirations
• C. Blood pressure
• D. Radial pulse rate

Correct answer: C

Rationale: The correct answer is checking the client's blood pressure (C) before administering another nitroglycerin tablet. Nitroglycerin can cause hypotension, and monitoring blood pressure is crucial to prevent a sudden drop in blood pressure, especially when giving another dose of nitroglycerin.

5. Mafenide acetate (Sulfamylon) is prescribed for a client with a burn injury. When applying the medication, the client complains of local discomfort and burning. Which of the following is the most appropriate nursing action?

• A. Notifying the registered nurse
• B. Discontinuing the medication
• C. Informing the client that this is normal
• D. Applying a thinner film than prescribed to the burn site

Correct answer: C

Rationale: The correct action is to inform the client that local discomfort and burning are normal reactions to Mafenide acetate. This medication is used to treat burns by reducing bacteria in avascular tissues. Discontinuing the medication or applying a thinner film than prescribed is not necessary or recommended in this situation.

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