Nursing Elites

1. When teaching a patient to take their own pulse, which medication should the nurse instruct them to monitor? (Hint: if pulse is <60 or >100, the patient should contact their healthcare provider before taking the medication)

• A. Digoxin
• B. Lithium
• C. Montelukast
• D. Phenytoin

Correct answer: A

Rationale: It is essential for patients taking Digoxin to monitor their pulse regularly. If their pulse falls below 60 or exceeds 100 beats per minute, they should contact their healthcare provider immediately. This is crucial due to Digoxin's potential to affect heart rate, making pulse monitoring a vital aspect of patient care while on this medication.

2. When administering Phenytoin, what should you monitor?

• A. Behavior
• B. Therapeutic blood levels
• C. For signs of Stevens-Johnson syndrome
• D. All of the above

Correct answer: D

Rationale: When administering Phenytoin, monitoring the patient's behavior is important to assess for any changes that may indicate adverse effects. Monitoring therapeutic blood levels helps ensure the medication is within the effective range and not causing toxicity. Additionally, being vigilant for signs of Stevens-Johnson syndrome, a severe skin reaction associated with Phenytoin use, is crucial for early detection and intervention. Therefore, monitoring behavior, therapeutic blood levels, and for signs of Stevens-Johnson syndrome are all essential when administering Phenytoin.

3. A client with Preeclampsia is receiving Magnesium Sulfate IV continuous infusion. Which of the following findings should the nurse report to the provider?

• A. 2+ deep tendon reflexes
• B. 2+ pedal edema
• C. 24 mL/hr urinary output
• D. Respirations 12/min

Correct answer: C

Rationale: In a client receiving Magnesium Sulfate IV for Preeclampsia, a urinary output less than 25 to 30 mL/hr indicates magnesium sulfate toxicity and should be reported to the provider for further evaluation and management. Choice A, 2+ deep tendon reflexes, is a normal finding with magnesium sulfate therapy. Choice B, 2+ pedal edema, is expected in clients with preeclampsia but does not indicate magnesium sulfate toxicity. Choice D, respirations 12/min, is within the normal range and not a concerning finding related to magnesium sulfate administration.

4. A client has a new prescription for a combination of oral NRTIs (abacavir, lamivudine, and zidovudine) for the treatment of HIV. Which of the following statements should the nurse include in teaching the client?

• A. These medications work by blocking HIV entry into cells.
• B. These medications work by weakening the cell wall of the HIV virus.
• C. These medications work by inhibiting enzymes to prevent HIV replication.
• D. These medications work by preventing protein synthesis within the HIV cell.

Correct answer: C

Rationale: The NRTI antiretroviral medications this client is prescribed work by inhibiting the enzyme reverse transcriptase, thus preventing HIV replication. By inhibiting this crucial enzyme, the drug interferes with the virus's ability to replicate and spread in the body. Choice A is incorrect because NRTIs do not block HIV entry into cells. Choice B is incorrect as NRTIs do not weaken the cell wall of the virus. Choice D is incorrect as NRTIs do not prevent protein synthesis within the HIV cell.

5. A client in labor is receiving IV Opioid analgesics. Which of the following actions should the nurse take?

• A. Instruct the client to self-ambulate every 2 hours.
• B. Offer oral hygiene every 2 hours.
• C. Anticipate medication administration 2 hours prior to delivery.
• D. Monitor fetal heart rate every 2 hours.

Correct answer: B

Rationale: When a client is receiving IV Opioid analgesics during labor, the nurse should offer oral hygiene every 2 hours. Opioid analgesics can cause adverse effects like dry mouth, nausea, and vomiting. Providing oral hygiene care helps alleviate these symptoms and maintains the client's comfort and well-being during labor. Instructing the client to self-ambulate every 2 hours is not appropriate during labor as mobility may be limited. Anticipating medication administration 2 hours prior to delivery is not necessary as the timing of medication administration should be based on the client's needs and the progress of labor. Monitoring fetal heart rate every 2 hours is important during labor, but it is not specifically related to the client receiving IV Opioid analgesics.

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