Nursing Elites

1. What nursing interventions should you perform when a patient is on Albuterol? (Select all that apply)

• A. Assess lung sounds, pulse, and blood pressure before administering
• B. Monitor for changes in behavior
• C. Observe for paradoxical bronchospasms
• D. Both A and C

Correct answer: D

Rationale: The correct nursing interventions to perform when a patient is on Albuterol include assessing the patient's lung sounds, pulse, and blood pressure before administering the medication to monitor for cardiovascular side effects like increased heart rate. Additionally, it is crucial to observe for paradoxical bronchospasms, a rare but serious adverse reaction where the medication causes a worsening of bronchospasm instead of relief. Monitoring for changes in behavior is not directly related to Albuterol administration and is not a standard nursing intervention for patients receiving this medication, making choice B incorrect. Therefore, the correct answer is D as it includes the essential nursing actions for patients on Albuterol.

2. A client has a prescription for Bethanechol to treat urinary retention. Which of the following findings is a manifestation of muscarinic stimulation?

• A. Dry mouth
• B. Hypertension
• C. Excessive perspiration
• D. Fecal impaction

Correct answer: C

Rationale: The correct answer is C: Excessive perspiration. Bethanechol is a muscarinic agonist that stimulates muscarinic receptors. Activation of muscarinic receptors can lead to excessive perspiration (diaphoresis) due to increased cholinergic activity, affecting sweat glands. Dry mouth, hypertension, and fecal impaction are not typically associated with muscarinic stimulation. Dry mouth is more commonly associated with anticholinergic medications, hypertension can be a result of alpha-adrenergic stimulation, and fecal impaction is not a direct effect of muscarinic receptor activation.

3. When starting a new prescription for prednisone, which instruction should the nurse include for the client?

• A. Increase your intake of potassium-rich foods.
• B. Do not stop taking this medication abruptly.
• C. Avoid grapefruit juice while taking this medication.
• D. Take the medication at bedtime to prevent drowsiness.

Correct answer: B

Rationale: The correct instruction for a client starting a new prescription for prednisone is not to stop taking the medication abruptly. Abrupt discontinuation of prednisone can lead to adrenal insufficiency, emphasizing the importance of gradual tapering under healthcare provider guidance. Increasing potassium-rich foods may be necessary based on individual needs, but it is not the priority instruction in this context. Grapefruit juice interaction is more commonly associated with certain medications but not specifically with prednisone. Taking prednisone at bedtime to prevent drowsiness is not a key instruction related to its administration.

4. 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 continuous infusion for Preeclampsia, a urinary output less than 25 to 30 mL/hr is indicative of magnesium sulfate toxicity and should be promptly reported to the provider for further evaluation and management. Therefore, the correct answer is C. Option A, 2+ deep tendon reflexes, are expected findings in a client receiving magnesium sulfate and do not require immediate reporting. Option B, 2+ pedal edema, is a common symptom of preeclampsia and typically does not require immediate intervention. Option D, respirations 12/min, are within the normal range and do not indicate an immediate need for reporting to the provider.

5. A child is prescribed Amoxicillin 20 mg/kg/day PO to be administered every 12 hr. The child weighs 44 lb. The available medication is amoxicillin suspension 250 mg/5 mL. How many mL should be given per dose?

• A. 4 mL
• B. 5 mL
• C. 6 mL
• D. 3 mL

Correct answer: A

Rationale: To calculate the dosage per administration: Convert the weight to kg (44 lb / 2.2 lb/kg = 20 kg). Then, (20 mg/kg/day x 20 kg) / 2 (for every 12 hr dosing) = 200 mg per dose. (200 mg / 250 mg) x 5 mL = 4 mL per dose. Therefore, the nurse should administer 4 mL of amoxicillin suspension per dose. Choice B, 5 mL, is incorrect because the calculation shows that 4 mL is the correct dose. Choices C and D are also incorrect as they are not in line with the calculated dosage based on the weight of the child and the concentration of the medication.

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