Nursing Elites

1. A client taking nitroglycerin (Nitrostat) for angina asks the nurse to explain possible side effects. What should NOT be included in client teaching?

• A. Reflex tachycardia
• B. Dizziness
• C. Hyponatremia
• D. Hypotension

Correct answer: C

Rationale: Hyponatremia is not a common side effect associated with nitroglycerin use. Nitroglycerin typically causes side effects such as reflex tachycardia, dizziness, and hypotension due to its vasodilatory effects. Therefore, it is important for the nurse to educate the client about these potential side effects to promote understanding and appropriate management.

2. A healthcare provider is reviewing the medical history of a client who is scheduled for surgery and takes Warfarin daily. Which of the following laboratory results should the healthcare provider monitor?

• A. Potassium level
• B. INR
• C. BUN
• D. Platelet count

Correct answer: B

Rationale: The INR (International Normalized Ratio) is the most important lab value to monitor in a client taking warfarin. Warfarin is an anticoagulant, and the INR reflects the effectiveness of anticoagulation therapy. Monitoring the INR helps ensure the client is within the therapeutic range to prevent both clotting and bleeding complications.

3. A client is receiving heparin therapy. Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the therapy?

• A. PT
• B. aPTT
• C. INR
• D. Platelet count

Correct answer: B

Rationale: The corrected answer is B: aPTT. The activated partial thromboplastin time (aPTT) is the laboratory value used to monitor the effectiveness of heparin therapy. The aPTT should be maintained at 1.5 to 2 times the normal level to ensure therapeutic anticoagulation. Monitoring aPTT helps healthcare providers adjust heparin doses to achieve the desired anticoagulant effects and prevent complications such as bleeding or clotting. Choice A, PT (prothrombin time), is used to monitor warfarin therapy, not heparin. Choice C, INR (international normalized ratio), is also used to monitor warfarin therapy. Choice D, platelet count, is important for assessing the risk of bleeding, but it does not directly monitor the effectiveness of heparin therapy.

4. A client in labor is receiving IV Opioid analgesics. Which of the following actions should the nurse take?

• A. Instruct the client to self-ambulate every 2 hours.
• B. Offer oral hygiene every 2 hours.
• C. Anticipate medication administration 2 hours prior to delivery.
• D. Monitor fetal heart rate every 2 hours.

Correct answer: B

Rationale: Offering oral hygiene every 2 hours is essential for a client receiving opioid analgesics to prevent dry mouth, nausea, and vomiting, which are common adverse effects associated with opioid use. This intervention promotes comfort and enhances the client's well-being during labor. Instructing the client to self-ambulate every 2 hours is not appropriate for a client in labor receiving opioid analgesics, as it may be challenging and unnecessary during this time. Anticipating medication administration 2 hours prior to delivery is not necessary as the timing of medication administration should be based on the client's pain level and the duration of action of the opioid. Monitoring fetal heart rate every 2 hours is important during labor, but the priority in this case is to address the client's comfort and well-being by offering oral hygiene.

5. In which of the following cases is Lansoprazole not used?

• A. Gastritis
• B. Peptic Ulcers
• C. Zollinger-Ellison syndrome
• D. Thalamus hypertrophy

Correct answer: D

Rationale: Lansoprazole is a proton pump inhibitor mainly used to treat conditions related to the stomach, such as gastritis, peptic ulcers, and Zollinger-Ellison syndrome. Thalamus hypertrophy is not a condition that Lansoprazole is indicated for; it is used for gastrointestinal issues and not neurological conditions.

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