Nursing Elites

1. A nurse is caring for a client receiving IV vancomycin. The nurse notes flushing of the client's neck and chest. Which of the following actions should the nurse take?

• A. Stop the infusion
• B. Document the findings as a harmless reaction
• C. Slow the infusion rate
• D. Administer diphenhydramine

Correct answer: C

Rationale: The correct action for the nurse to take when a client receiving IV vancomycin shows flushing of the neck and chest is to slow the infusion rate. Flushing is a common sign of Red Man Syndrome, which is associated with rapid infusions of vancomycin. Slowing down the infusion rate can help prevent further flushing and the development of Red Man Syndrome. Stopping the infusion (Choice A) may be too drastic if the symptoms are mild and can be managed by slowing the rate. Documenting the findings as a harmless reaction (Choice B) is incorrect because flushing should be addressed promptly to prevent complications. Administering diphenhydramine (Choice D) is not the initial or best intervention for flushing associated with vancomycin; slowing the infusion rate is the priority.

2. A nurse is reviewing the medical record of a client who is prescribed acetaminophen for pain. Which of the following lab values should the nurse monitor to identify an adverse effect of the medication?

• A. Serum glucose
• B. Serum creatinine
• C. Serum potassium
• D. Serum bilirubin

Correct answer: B

Rationale: The correct answer is B: Serum creatinine. Acetaminophen is metabolized by the liver, so serum creatinine levels should be monitored for potential hepatotoxicity. Monitoring serum creatinine can help detect liver damage, a potential adverse effect of acetaminophen. Choices A, C, and D are incorrect because serum glucose is not directly affected by acetaminophen, serum potassium is not typically monitored for acetaminophen adverse effects, and serum bilirubin is more related to bile metabolism rather than acetaminophen-induced hepatotoxicity.

3. A nurse is preparing to administer metoprolol to a client with hypertension. Which of the following should the nurse assess prior to administering this medication?

• A. Temperature
• B. Heart rate
• C. Respiratory rate
• D. Blood pressure

Correct answer: D

Rationale: The correct answer is D: Blood pressure. Before administering metoprolol, a beta-blocker commonly used to treat hypertension, the nurse should assess the client's blood pressure. Metoprolol works by lowering blood pressure and reducing the workload on the heart. Assessing the blood pressure is crucial to ensure it is within the acceptable range to administer the medication safely. Choices A, B, and C (Temperature, Heart rate, Respiratory rate) are important assessments in general patient care but are not specifically required before administering metoprolol for hypertension.

4. A nurse is providing client education regarding lithium therapy. Which of the following instructions should the nurse include?

• A. Take with food to decrease nausea
• B. Avoid excessive intake of caffeinated beverages
• C. Monitor for signs of dehydration
• D. Restrict salt intake to prevent water retention

Correct answer: B

Rationale: The correct answer is B. The nurse should instruct the client to avoid excessive intake of caffeinated beverages as they can interfere with lithium levels. Option A is incorrect as lithium is usually recommended to be taken on an empty stomach. Option C is not directly related to lithium therapy. Option D is not a typical instruction for lithium therapy.

5. A 52-year-old client with a history of angina has been prescribed transdermal nitroglycerin. Which of the following adverse effects is not associated with this therapy?

• A. Tolerance
• B. Orthostatic hypotension
• C. Headache
• D. Productive cough

Correct answer: D

Rationale: The correct answer is D: Productive cough. Nitroglycerin therapy can lead to adverse effects such as tolerance, orthostatic hypotension, and headache. However, it is not known to cause a productive cough. Tolerance may develop over time, requiring dose adjustments. Orthostatic hypotension can occur due to vasodilation effects, leading to a sudden drop in blood pressure when changing positions. Headache is a common side effect due to vasodilation of cranial blood vessels. Productive cough is not a recognized adverse effect associated with transdermal nitroglycerin therapy.

Similar Questions