Nursing Elites

1. A client diagnosed with a herniated disc is prescribed hydrocodone/acetaminophen 10 mg/300 mg prn every 4 to 6 hours. As the practical nurse (PN) enters the client's room to administer the requested medication, the client is seen talking and laughing with visiting family. What action should the PN take?

• A. Hold the pain medication until after the visitors leave.
• B. Notify the healthcare provider of the client's drug-seeking behavior.
• C. Administer analgesia as requested by the client.
• D. Inform the client that the medication is not needed based on their behavior.

Correct answer: C

Rationale: The correct action for the PN in this situation is to administer the analgesia as requested by the client. Pain management is based on the client's self-report of pain, which is the most reliable indicator of pain intensity. Analgesics should be given promptly when pain occurs and before it worsens. Following the administration of medication, the PN should discuss the situation with the charge nurse for further guidance or assessment.

2. A client with rheumatoid arthritis is prescribed methotrexate. The nurse should monitor for which common side effect of this medication?

• A. Liver toxicity
• B. Skin rash
• C. Hair loss
• D. Abdominal pain

Correct answer: A

Rationale: The correct answer is A: Liver toxicity. Methotrexate is known to cause liver toxicity, making regular monitoring of liver function essential. Monitoring liver function tests helps detect any signs of liver damage early, allowing for appropriate interventions to be implemented promptly.

3. A client with a history of deep vein thrombosis is prescribed enoxaparin. The nurse should monitor for which potential adverse effect?

• A. Increased risk of bleeding
• B. Decreased risk of bleeding
• C. Increased risk of infection
• D. Decreased risk of infection

Correct answer: A

Rationale: Enoxaparin is an anticoagulant that works by preventing blood clots. One of the potential adverse effects of enoxaparin is an increased risk of bleeding due to its anticoagulant properties. Therefore, the nurse should monitor the client for signs of bleeding, such as easy bruising, petechiae, or blood in stool or urine, to ensure timely intervention and prevent complications.

4. The client is receiving vancomycin, and the nurse plans to draw blood for a peak and trough to determine... the best timing for these levels?

• A. Midway through administration of the IV dose and 30 minutes before the next
• B. Two hours after completion of the IV dose and 30 minutes before the next
• C. Two hours after completion of the IV dose and one hour before the next
• D. Immediately after completion of the IV dose and 30 minutes before

Correct answer: B

Rationale: To accurately determine peak and trough levels of vancomycin, blood should be drawn two hours after the completion of the IV dose and 30 minutes before the next dose. This timing allows for appropriate assessment of the drug levels in the body, ensuring accurate monitoring of therapeutic and toxic concentrations. Choice A is incorrect as drawing blood midway through administration does not provide an accurate peak level. Choice C is incorrect as drawing blood one hour before the next dose does not represent the trough level. Choice D is incorrect because drawing blood immediately after completion of the IV dose does not allow enough time for the drug to reach peak levels.

5. When should a glucagon emergency kit be used for a client with Type 1 diabetes?

• A. During episodes of hypoglycemia
• B. At the onset of signs of diabetic ketoacidosis
• C. Before meals to prevent hyperglycemia
• D. When signs of severe hypoglycemia occur

Correct answer: D

Rationale: A glucagon emergency kit is used when signs of severe hypoglycemia occur in a client with Type 1 diabetes. Glucagon helps raise blood glucose levels in cases of severe hypoglycemia when the individual is unable to take oral glucose. It is crucial to administer glucagon promptly to prevent serious complications associated with low blood sugar levels. Choices A, B, and C are incorrect because a glucagon emergency kit is specifically indicated for severe hypoglycemia, not for general episodes of hypoglycemia, diabetic ketoacidosis, or prevention of hyperglycemia.

Similar Questions