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. A patient with irritable bowel syndrome starts a new prescription for dicyclomine, an anticholinergic medication. The client reports the onset of sensitivity to light and a dry mouth. How should the nurse respond?

• A. Determine if the medication is being taken correctly
• B. Provide instructions on managing these side effects
• C. Schedule an appointment for evaluation by the healthcare provider
• D. Advise stopping the medication until the unpleasant side effects wear off

Correct answer: B

Rationale: The correct response is to provide instructions on managing these side effects. Sensitivity to light and dry mouth are common side effects of anticholinergic medications like dicyclomine. It is essential for the nurse to educate the patient on strategies to cope with these side effects, such as staying hydrated to address dry mouth and wearing sunglasses to reduce sensitivity to light. Option A is not the priority as the side effects are expected with this medication and do not necessarily indicate incorrect use. Option C is not immediately necessary as the side effects are common and can be managed without a healthcare provider evaluation. Option D is not recommended unless advised by the healthcare provider as abruptly stopping the medication can lead to worsening symptoms or withdrawal effects.

3. A client with a history of deep vein thrombosis is prescribed edoxaban. 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: The correct answer is A: Increased risk of bleeding. Edoxaban is an anticoagulant that works by inhibiting clot formation, thereby increasing the risk of bleeding. Therefore, the nurse should closely monitor the client for signs of bleeding, such as bruising, petechiae, hematuria, or gastrointestinal bleeding, to prevent potential complications. Choices B, C, and D are incorrect because edoxaban does not decrease the risk of bleeding or affect the risk of infection; its primary concern is the potential for bleeding due to its anticoagulant properties.

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

• A. Hyperkalemia
• B. Hypokalemia
• C. Hypernatremia
• D. Hyponatremia

Correct answer: B

Rationale: When a client is prescribed hydrochlorothiazide, the nurse should monitor for hypokalemia as a potential side effect. Hydrochlorothiazide is a diuretic that can lead to potassium loss, hence monitoring potassium levels is crucial to prevent complications related to hypokalemia.

5. A client with a diagnosis of generalized anxiety disorder is prescribed venlafaxine. The nurse should instruct the client that this medication may have which potential side effect?

• A. Nausea
• B. Dry mouth
• C. Insomnia
• D. Headache

Correct answer: A

Rationale: The correct answer is A: Nausea. Venlafaxine, a medication used for generalized anxiety disorder, can commonly cause nausea as a side effect. It is essential for clients to be aware of this potential side effect and advised to take the medication with food if nausea occurs. Choices B, C, and D are incorrect because dry mouth, insomnia, and headache are less commonly associated side effects of venlafaxine compared to nausea.

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