Nursing Elites

1. A client with asthma is receiving long-term glucocorticoid therapy. The nurse includes a risk for impaired skin integrity on the client's problem list. What is the rationale for including this problem?

• A. Abnormal fat deposits impair circulation
• B. Frequent diarrhea can lead to skin issues
• C. Thinned skin bruises easily
• D. Decreased serum glucose prolongs healing time

Correct answer: C

Rationale: The correct answer is C. Glucocorticoids can cause skin thinning, which increases the likelihood of bruising. Thinning of the skin due to glucocorticoid therapy makes it more fragile and prone to injury, such as bruising, even with minimal trauma. Choices A, B, and D are incorrect because abnormal fat deposits impairing circulation, frequent diarrhea causing skin issues, and decreased serum glucose prolonging healing time are not direct effects of glucocorticoid therapy on skin integrity.

2. 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.

3. A client with a diagnosis of schizophrenia is prescribed risperidone. The nurse should monitor for which potential side effect?

• A. Weight gain
• B. Tremors
• C. Insomnia
• D. Hyperglycemia

Correct answer: A

Rationale: The correct answer is A: Weight gain. When a client is prescribed risperidone, monitoring weight is crucial due to the potential side effect of weight gain associated with this medication. This side effect can be significant as it may lead to other health issues. Choice B, Tremors, is not typically associated with risperidone use. Choice C, Insomnia, is less likely to be a direct side effect of risperidone compared to weight gain. Choice D, Hyperglycemia, is a possible side effect of some antipsychotic medications, but it is not commonly associated with risperidone.

4. A male client receives a scopolamine transdermal patch 2 hours before surgery. Four hours after surgery, the client tells the nurse that he is experiencing pain and asks why the patch is not working. Which action should the nurse take?

• A. Advise the client that the effects of the medication have worn off
• B. Explain that the medication is not given to relieve pain
• C. Check for the correct placement of the patch on the client
• D. Offer to apply a new transdermal patch to address the pain

Correct answer: B

Rationale: The correct answer is B. Scopolamine is not a pain medication; it is commonly used to prevent nausea and vomiting, particularly in surgical settings. It works on the central nervous system to help control these symptoms, not to relieve pain. Therefore, it is important for the nurse to explain to the client that the medication is not intended to relieve pain but rather to manage other specific symptoms. Checking the correct placement of the patch is also important to ensure proper administration, but addressing the misconception about the medication's purpose is the priority in this scenario. Offering to apply a new patch would not address the client's pain as scopolamine is not meant for pain relief. Advising the client that the effects have worn off is inaccurate because the medication is not used for pain management.

5. A client is taking levodopa-carbidopa for Parkinson's disease. The nurse should include which instruction when educating the client about this medication?

• A. Increase fluid intake to prevent dehydration.
• B. Take medication with food to improve absorption.
• C. Take medication at bedtime to avoid daytime drowsiness.
• D. It can cause nausea and dizziness.

Correct answer: A

Rationale: The correct instruction for a client taking levodopa-carbidopa for Parkinson's disease is to increase fluid intake to prevent dehydration. Levodopa-carbidopa should be taken with food to reduce gastrointestinal upset and improve absorption. Taking medication at bedtime is not necessary to avoid daytime drowsiness. It is crucial to prevent dehydration due to the medication's side effects. Choice B is incorrect because the medication should be taken with food, not at bedtime. Choice C is incorrect as taking the medication with food, rather than on an empty stomach, aids in absorption and reduces gastrointestinal side effects. Choice D is incorrect as it states the side effects of the medication rather than providing specific instructions on its administration.

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