Nursing Elites

1. When a nurse assesses a client's IV catheter insertion site and notes a hematoma, which of the following actions should the nurse take? (Select all that apply.)

• A. Stop the infusion.
• B. Apply alcohol to the insertion site.
• C. Apply warm compresses to the insertion site.
• D. Elevate the client's arm.

Correct answer: C

Rationale: When a nurse detects a hematoma at the IV catheter insertion site, applying warm compresses is beneficial as it can promote healing by enhancing circulation and reducing swelling. Elevating the client's arm helps in reducing edema, which can relieve pressure, pain, and further bleeding in the hematoma area. Stopping the infusion may be necessary in certain situations, but it is not a standard action for all hematoma cases. Applying alcohol to the insertion site is discouraged as it can cause irritation and may not aid in resolving the hematoma.

2. A client is prescribed Lithium. Which of the following laboratory values should be monitored to assess for potential toxicity?

• A. Serum sodium
• B. Serum lithium
• C. Serum potassium
• D. Serum calcium

Correct answer: B

Rationale: When a client is prescribed Lithium, monitoring serum lithium levels is crucial to ensure they remain within the therapeutic range and to assess for potential toxicity. Monitoring serum lithium levels helps prevent adverse effects associated with lithium toxicity, such as nausea, vomiting, diarrhea, tremors, and confusion.

3. A client has a prescription for Hydrochlorothiazide. Which of the following instructions should the nurse include?

• A. Take this medication in the morning.
• B. Increase intake of potassium-rich foods.
• C. Take this medication with food.
• D. Monitor for signs of dehydration.

Correct answer: D

Rationale: The correct answer is to monitor for signs of dehydration. Hydrochlorothiazide is a diuretic that can lead to fluid loss and electrolyte imbalance, potentially causing dehydration. Signs of dehydration include dry mouth, increased thirst, and decreased urine output. It is important for the client to be vigilant in monitoring and reporting these symptoms to healthcare providers to prevent complications. Choices A, B, and C are incorrect because taking the medication in the morning, increasing potassium-rich foods, or taking the medication with food are not specific instructions related to the potential side effects of Hydrochlorothiazide.

4. A client with a prescription for Vasopressin to treat Diabetes Insipidus is being taught by a healthcare professional. Which of the following client statements indicates an understanding of the teaching?

• A. I will reduce my sodium intake.
• B. I should increase my water intake.
• C. I will notify my doctor if I develop chest pain.
• D. I should take this medication with food.

Correct answer: C

Rationale: The correct answer is C because Vasopressin can cause vasoconstriction, potentially leading to chest pain. It is crucial for the client to inform their healthcare provider immediately if they experience chest pain while on Vasopressin therapy to address any potential cardiovascular complications promptly. Choices A, B, and D are incorrect. While maintaining adequate hydration is essential with Vasopressin therapy due to its antidiuretic effect, increasing water intake is not the most critical aspect to monitor. Reducing sodium intake may be beneficial in some cases but is not directly related to the potential side effects of Vasopressin. Taking the medication with food is not a specific instruction for Vasopressin administration.

5. A client has a new prescription for Metronidazole. Which of the following instructions should be included?

• A. Avoid drinking alcohol while taking this medication.
• B. Take the medication on an empty stomach.
• C. Increase your intake of green, leafy vegetables.
• D. Discontinue the medication if you experience a metallic taste.

Correct answer: A

Rationale: The correct instruction for a client prescribed Metronidazole is to avoid drinking alcohol while taking this medication. Metronidazole can cause a disulfiram-like reaction when combined with alcohol, resulting in severe nausea, vomiting, and other adverse effects. Therefore, it is crucial for clients to refrain from consuming alcohol during treatment to prevent these potential complications. Choice B is incorrect because Metronidazole can be taken with or without food. Choice C is irrelevant as there is no specific requirement to increase green, leafy vegetable intake with Metronidazole. Choice D is incorrect as a metallic taste is a known side effect of Metronidazole but does not necessarily indicate the need to discontinue the medication.

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