Nursing Elites

1. A client who is obtunded arrives in the emergency center with a suspected drug overdose. Intravenous naloxone is given, but within a short period, the client's level of consciousness deteriorates. What action should the nurse take first?

• A. Initiate a second intravenous access site
• B. Prepare to initiate cardiopulmonary resuscitation
• C. Determine the results of the drug toxicity screen
• D. Administer an additional dose of naloxone

Correct answer: D

Rationale: Administering an additional dose of naloxone should be the first action taken by the nurse in this scenario. Naloxone is an opioid antagonist used to reverse the effects of opioid overdose. If the client's level of consciousness deteriorates after the initial dose, administering another dose can help further reverse the overdose effects and improve the client's condition. Once the additional naloxone dose is given, the nurse can then proceed to assess the client's response and consider other interventions as needed.

2. Phenazopyridine is commonly prescribed for clients with urinary tract infections (UTI). Which statement by the practical nurse describes the purpose for the administration of phenazopyridine?

• A. To alter the pH level of the urine
• B. To reduce the frequency of bladder spasms
• C. To alleviate the painful symptoms caused by the UTI
• D. To prevent bacterial replication and resistance development

Correct answer: C

Rationale: The correct answer is C. Phenazopyridine, a urinary analgesic, is utilized to alleviate the pain associated with urinary tract infections (UTIs) like burning, pain, urgency, and frequent voiding. The administration of phenazopyridine can cause the urine to turn a bright red-orange color. It is recommended to take this medication with food to reduce gastric irritation. Phenazopyridine should only be used for a maximum of 2 days when taken alongside an antibacterial agent, which is typically prescribed for about 2 weeks to treat the underlying infection.

3. A client with diabetes mellitus type 2 is prescribed sitagliptin. The nurse should monitor for which potential adverse effect?

• A. Pancreatitis
• B. Hypoglycemia
• C. Hyperglycemia
• D. Nausea

Correct answer: A

Rationale: Corrected Rationale: Sitagliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor used in type 2 diabetes, has been associated with rare cases of pancreatitis. Therefore, the nurse should monitor for signs and symptoms of pancreatitis such as severe abdominal pain, nausea, and vomiting. While hypoglycemia is a potential adverse effect of some diabetes medications, it is less common with sitagliptin. Hyperglycemia is the condition being treated and is not an expected adverse effect of sitagliptin.

4. A client with hypertension is prescribed clonidine. The nurse should monitor the client for which potential side effect?

• A. Hypotension
• B. Tachycardia
• C. Dizziness
• D. Hyperglycemia

Correct answer: A

Rationale: The correct answer is A: Hypotension. Clonidine, a medication used to treat hypertension, can cause a lowering of blood pressure leading to hypotension as a potential side effect. Monitoring for hypotension is essential to prevent complications such as dizziness, fainting, or falls. Option B, Tachycardia, is incorrect as clonidine typically causes bradycardia or a decreased heart rate. Option C, Dizziness, can occur due to hypotension caused by clonidine. Option D, Hyperglycemia, is not a common side effect associated with clonidine use.

5. Twenty-four hours after starting to take oral penicillin for strep throat, a client calls the nurse to report the onset of a rash on the chest. What action should the nurse implement?

• A. Instruct the client to discontinue the penicillin immediately
• B. Instruct the client regarding the use of topical analgesic cream PRN
• C. Question the client about any other related symptoms
• D. Reinforce the need to take all doses of the penicillin

Correct answer: A

Rationale: In this scenario, the client has developed a rash after starting oral penicillin, which can indicate an allergic reaction. It is crucial for the nurse to instruct the client to discontinue the penicillin immediately. Continuing the medication can potentially lead to severe allergic reactions. Instructing about topical analgesic cream or questioning about other related symptoms may delay appropriate action in case of a severe allergic reaction. Reinforcing the need to complete all doses is not appropriate when an allergic reaction is suspected, as safety takes precedence over completing the antibiotic course.

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