Nursing Elites

1. Which nursing intervention is most important when caring for a client receiving aspirin 600mg po QID?

• A. Monitor temperature q4h
• B. Use 10-point pain scale to assess pain
• C. Assess for dyspepsia and nausea
• D. Check stool for occult blood

Correct answer: D

Rationale: The correct answer is to check the stool for occult blood when caring for a client receiving aspirin 600mg po QID. Aspirin can lead to gastrointestinal bleeding, and checking for occult blood in the stool is essential to monitor for this serious adverse effect. Monitoring temperature, assessing pain, and checking for dyspepsia and nausea are important interventions but not as critical as monitoring for gastrointestinal bleeding when a client is receiving aspirin.

2. A client with chronic kidney disease is prescribed sevelamer. The nurse should monitor for which potential side effect?

• A. Hypercalcemia
• B. Hypocalcemia
• C. Hyperkalemia
• D. Hypokalemia

Correct answer: B

Rationale: When a client with chronic kidney disease is prescribed sevelamer, the nurse should monitor for hypocalcemia. Sevelamer works by binding dietary phosphorus in the gastrointestinal tract, which can lead to decreased calcium absorption and potentially cause hypocalcemia.

3. A client is receiving heparin to treat a deep vein thrombosis. The nurse should monitor which laboratory result to assist in evaluating the efficacy of the drug?

• A. Platelet count
• B. Prothrombin time
• C. Partial thromboplastin time
• D. Serum levels of protamine sulfate

Correct answer: C

Rationale: The nurse should monitor the partial thromboplastin time to evaluate the efficacy of heparin. Partial thromboplastin time reflects the anticoagulant effect of heparin by measuring the intrinsic pathway of coagulation. Platelet count assesses platelet levels and is not specific to heparin efficacy. Prothrombin time is used to monitor warfarin therapy. Serum levels of protamine sulfate are not used to evaluate the efficacy of heparin.

4. A practical nurse (PN) is preparing to administer enoxaparin to a client. What is the most important action for the PN to take before administering this medication?

• A. Assess the client's blood pressure.
• B. Check the client's platelet count.
• C. Monitor the client's urine output.
• D. Review the client's blood glucose level.

Correct answer: B

Rationale: The correct answer is to check the client's platelet count. Enoxaparin can lead to thrombocytopenia (low platelet count), which can increase the risk of bleeding. Therefore, assessing the platelet count before administering enoxaparin is crucial to ensure that it is within a safe range. Assessing the client's blood pressure (Choice A) is not directly related to enoxaparin administration. Monitoring urine output (Choice C) and reviewing blood glucose levels (Choice D) are not essential actions before administering enoxaparin.

5. A client is prescribed atorvastatin. The practical nurse should monitor the client for which potential adverse effect?

• A. Muscle pain and weakness
• B. Headache
• C. Hepatotoxicity
• D. Gastrointestinal bleeding

Correct answer: A

Rationale: The correct answer is A: Muscle pain and weakness. Atorvastatin is known to potentially cause muscle pain and weakness, which could indicate muscle damage or rhabdomyolysis. This adverse effect should be closely monitored by the practical nurse to ensure early detection and appropriate management. Choices B, C, and D are incorrect because they are not typically associated with atorvastatin use. Headache is a less common side effect, hepatotoxicity is rare but serious, and gastrointestinal bleeding is not a common adverse effect of atorvastatin.

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