Nursing Elites

1. A client receiving codeine for pain every 4 to 6 hours over 4 days. Which assessment should the nurse perform before administering the next dose?

• A. Auscultate the bowel sounds.
• B. Palpate the ankles for edema.
• C. Observe the skin for bruising.
• D. Measure the body temperature.

Correct answer: A

Rationale: The correct answer is A: Auscultate the bowel sounds. Codeine is known to cause constipation, so it is essential to assess bowel sounds before administering another dose to monitor for potential constipation or bowel motility issues. Palpating the ankles for edema (Choice B) is not directly related to codeine use or its side effects. Observing the skin for bruising (Choice C) is important but not specifically associated with codeine administration. Measuring body temperature (Choice D) is not a priority assessment related to codeine use; monitoring for constipation is more critical in this case.

2. The client is being taught about precautions with Coumadin therapy. The client should be instructed to avoid which over-the-counter medication?

• A. Non-steroidal anti-inflammatory drugs
• B. Cough medicines containing guaifenesin
• C. Histamine blockers
• D. Laxatives containing magnesium salts

Correct answer: A

Rationale: The correct answer is A: Non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs can increase the risk of bleeding in clients taking Coumadin, which is an anticoagulant medication. Avoiding NSAIDs helps prevent potentially dangerous interactions with Coumadin. Choices B, C, and D are incorrect. Cough medicines with guaifenesin, histamine blockers, and laxatives containing magnesium salts do not typically have significant interactions with Coumadin therapy. Therefore, they are not the over-the-counter medications that the client needs to avoid while on Coumadin.

3. A client is receiving 30 mg of enoxaparin subcutaneously twice a day. In assessing adverse effects of the medication, which serum laboratory value is most important for the nurse to monitor?

• A. Hemoglobin level
• B. Platelet count
• C. Activated partial thromboplastin time (aPTT)
• D. Prothrombin time (PT)

Correct answer: B

Rationale: The correct answer is B: Platelet count. Enoxaparin can cause heparin-induced thrombocytopenia (HIT), making it crucial to monitor the platelet count for signs of thrombocytopenia. Monitoring the platelet count helps in early detection of this serious adverse effect. Choices A, C, and D are less relevant in this context. Hemoglobin level checks are more indicative of bleeding issues rather than thrombocytopenia caused by enoxaparin. Activated partial thromboplastin time (aPTT) and prothrombin time (PT) are less impacted by enoxaparin and are not typically used to monitor for HIT.

4. A client is receiving a blood transfusion and reports feeling chilled and short of breath. What is the nurse's priority action?

• A. Stop the transfusion and notify the healthcare provider.
• B. Administer an antihistamine as prescribed.
• C. Administer a dose of acetaminophen.
• D. Administer a PRN dose of diphenhydramine.

Correct answer: A

Rationale: The correct action for the nurse to take when a client receiving a blood transfusion reports feeling chilled and short of breath is to stop the transfusion immediately and notify the healthcare provider. These symptoms could indicate a transfusion reaction, which can be serious and even life-threatening. Stopping the transfusion is crucial to prevent further adverse reactions, and notifying the healthcare provider ensures timely intervention and appropriate management. Administering antihistamines, acetaminophen, or diphenhydramine is not the priority in this situation and may delay necessary actions to address the potential transfusion reaction.

5. A male client admitted for schizophrenia is noted to be diaphoretic and pacing the hallway. What is the most important intervention?

• A. Take the client's temperature and blood pressure.
• B. Encourage the client to rest.
• C. Plan an activity involving physical exercise.
• D. Carefully observe the client throughout the shift.

Correct answer: D

Rationale: In this scenario, the most important intervention for a male client with schizophrenia who is diaphoretic and pacing the hallway is to carefully observe the client throughout the shift. Diaphoresis and pacing can be indicators of agitation or distress in clients with schizophrenia. Careful observation is crucial to monitor the client's safety, assess for any potential escalation of symptoms, and provide timely intervention if needed. Taking the client's temperature and blood pressure (Choice A) may not address the immediate need for safety and observation. Encouraging the client to rest (Choice B) may not be effective if the client is agitated. Planning an activity involving physical exercise (Choice C) could potentially exacerbate the situation rather than addressing the immediate need for observation and safety.

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