Nursing Elites

1. Why is prostaglandin E1 prescribed for a child with transposition of the great arteries?

• A. Prevents hypercyanotic (blue or tet) spells
• B. Maintains an adequate hormone level
• C. Maintains the position of the great arteries
• D. Provides adequate oxygen saturation and maintains cardiac output

Correct answer: D

Rationale: Prostaglandin E1 is prescribed for a child with transposition of the great arteries to increase blood mixing, which helps maintain adequate oxygen saturation and cardiac output. This medication does not prevent hypercyanotic spells, maintain hormone levels, or influence the position of the great arteries.

2. A client is receiving dietary instructions from a nurse regarding warfarin sodium (Coumadin) therapy. The nurse advises the client to avoid which food item?

• A. Grapes
• B. Spinach
• C. Watermelon
• D. Cottage cheese

Correct answer: B

Rationale: The correct answer is B: Spinach. Spinach is high in vitamin K, which antagonizes the effects of warfarin sodium, an anticoagulant medication. Clients taking warfarin should avoid consuming foods rich in vitamin K, like spinach, to maintain the medication's effectiveness. Grapes (choice A), watermelon (choice C), and cottage cheese (choice D) do not interfere with the effects of warfarin, so they are safe for the client to consume while on warfarin therapy.

3. A client is receiving morphine sulfate subcutaneously for pain. Because morphine sulfate has been prescribed for this client, which nursing action would be included in the plan of care?

• A. Encourage fluid intake.
• B. Monitor the client's temperature.
• C. Maintain the client in a supine position.
• D. Encourage the client to cough and deep breathe.

Correct answer: D

Rationale: Morphine sulfate suppresses the cough reflex, which can lead to the retention of secretions in the lungs. Encouraging the client to cough and deep breathe helps prevent pneumonia by clearing the airways of any accumulated secretions. This intervention is crucial in clients receiving morphine sulfate to maintain optimal respiratory function.

4. A client is taking docusate sodium (Colace). The nurse monitors which of the following to determine whether the client is experiencing a therapeutic effect from this medication?

• A. Abdominal pain
• B. Reduction in steatorrhea
• C. Hematest-negative stools
• D. Regular bowel movements

Correct answer: D

Rationale: The therapeutic effect of docusate sodium (Colace) is to soften stools and promote regular bowel movements, making option D the correct choice. Monitoring for regular bowel movements would indicate that the medication is working as intended by relieving or preventing constipation. Options A, B, and C are not directly related to the therapeutic effect of docusate sodium. Abdominal pain (option A) is a symptom that might indicate a problem rather than a therapeutic effect. Reduction in steatorrhea (option B) and Hematest-negative stools (option C) are not specific outcomes associated with docusate sodium.

5. A client is receiving vancomycin (Vancocin). Which of the following is the most important action for the nurse to take?

• A. Monitor the client for signs of nephrotoxicity.
• B. Monitor the client for signs of ototoxicity.
• C. Ensure adequate hydration.
• D. Administer the medication with food.

Correct answer: A

Rationale: The most important action for the nurse to take when a client is receiving vancomycin is to monitor for signs of nephrotoxicity. Vancomycin can cause kidney damage, so monitoring kidney function and signs of nephrotoxicity are crucial to prevent harm. While monitoring for ototoxicity and ensuring adequate hydration are important nursing actions, they are not as critical as preventing nephrotoxicity when administering vancomycin.

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