Nursing Elites

1. A client is taking cetirizine hydrochloride (Zyrtec). The nurse checks for which of the following side effects of this medication?

• A. Diarrhea
• B. Excitability
• C. Drowsiness
• D. Excess salivation

Correct answer: C

Rationale: Cetirizine hydrochloride (Zyrtec) is known to commonly cause drowsiness or sedation as a side effect. Therefore, the nurse should monitor the client for signs of drowsiness when administering this medication. Choice A, Diarrhea, is not a common side effect of cetirizine. Choice B, Excitability, is not a typical side effect of this antihistamine; instead, it tends to cause drowsiness. Choice D, Excess salivation, is not associated with cetirizine use.

2. The nurse provides medication instructions to an older hypertensive client who is taking 20 mg of lisinopril (Prinivil, Zestril) orally daily. The nurse evaluates the need for further teaching when the client states which of the following?

• A. I can skip a dose once a week.
• B. I need to change my position slowly.
• C. I take the pill after breakfast each day.
• D. If I get a bad headache, I should call my doctor immediately.

Correct answer: A

Rationale: Lisinopril should be taken daily as prescribed and not skipped. Skipping doses can lead to ineffective treatment.

3. When caring for a client with cancer receiving cisplatin, what adverse effects should the nurse monitor for? Select all that apply.

• A. Tinnitus
• B. Insomnia
• C. Hyperkalemia
• D. Hypercalcemia

Correct answer: A

Rationale: Cisplatin, a chemotherapy medication, can lead to various adverse effects, including ototoxicity manifesting as tinnitus, hypokalemia, hypocalcemia, hypomagnesemia, and nephrotoxicity. Therefore, the nurse should closely monitor for these side effects during the client's treatment.

4. A client is learning how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates the need for further teaching?

• A. Withdraws the NPH insulin first
• B. Withdraws the regular insulin first
• C. Injects air into the NPH insulin vial first
• D. Injects an amount of air equal to the desired dose of insulin into the vial

Correct answer: A

Rationale: When mixing regular insulin with another insulin preparation, it is crucial to withdraw the regular insulin first to prevent contamination. NPH insulin should be drawn after the regular insulin to maintain the integrity of each insulin type. Therefore, if the client withdraws the NPH insulin first, it indicates the need for further teaching. Choice B is correct as withdrawing regular insulin first is the appropriate step. Choice C is incorrect as air should be injected into the vial containing the regular insulin to maintain pressure. Choice D is incorrect as injecting air equal to the desired dose of insulin into the vial is a correct step in preparing the insulin for withdrawal.

5. The client with acute myelocytic leukemia is being treated with busulfan (Myleran). Which laboratory value should the nurse specifically monitor during treatment with this medication?

• A. Clotting time
• B. Uric acid level
• C. Potassium level
• D. Blood glucose level

Correct answer: B

Rationale: The correct answer is B, Uric acid level. Busulfan can cause an increase in uric acid levels, leading to hyperuricemia, renal stones, and acute renal failure. Monitoring uric acid levels is crucial to detect and manage potential complications associated with busulfan therapy.

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