Nursing Elites

1. A client is receiving morphine sulfate subcutaneously for pain. Because morphine sulfate has been prescribed for this client, which nursing action would be included in the plan of care?

• A. Encourage fluid intake.
• B. Monitor the client's temperature.
• C. Maintain the client in a supine position.
• D. Encourage the client to cough and deep breathe.

Correct answer: D

Rationale: Morphine sulfate suppresses the cough reflex, which can lead to the retention of secretions in the lungs. Encouraging the client to cough and deep breathe helps prevent pneumonia by clearing the airways of any accumulated secretions. This intervention is crucial in clients receiving morphine sulfate to maintain optimal respiratory function.

2. When a client taking warfarin sodium (Coumadin) is prescribed ciprofloxacin (Cipro), the nurse should closely monitor the client for which potential effect of this drug interaction?

• A. Increased risk of bleeding
• B. Decreased warfarin effectiveness
• C. Increased risk of thrombosis
• D. Decreased ciprofloxacin effectiveness

Correct answer: A

Rationale: When ciprofloxacin (Cipro) is given with warfarin sodium (Coumadin), it can potentiate the effects of warfarin, leading to an increased risk of bleeding. Therefore, the nurse should closely monitor the client's INR levels and watch for signs of bleeding such as bruising, petechiae, or black tarry stools.

3. A client is being educated about the use of sertraline (Zoloft) for depression. Which statement by the client indicates a need for further teaching?

• A. I should take the medication with a high-protein meal.
• B. I may experience dizziness when getting up quickly.
• C. I might notice a decrease in my sex drive.
• D. I should report any thoughts of self-harm to my healthcare provider.

Correct answer: A

Rationale: The statement 'I should take the medication with a high-protein meal' indicates a need for further teaching as sertraline (Zoloft) should not be taken with a high-protein meal due to potential interference with medication absorption. Choices B, C, and D are correct statements associated with the use of sertraline for depression. It is common to experience dizziness when quickly getting up, notice a decrease in sex drive, and important to report any thoughts of self-harm to the healthcare provider while on this medication.

4. A clinic nurse prepares to administer an MMR (measles, mumps, rubella) vaccine to a child. How is this vaccine best administered?

• A. Intramuscularly in the deltoid muscle
• B. Subcutaneously in the gluteal muscle
• C. Subcutaneously in the outer aspect of the upper arm
• D. Intramuscularly in the anterolateral aspect of the thigh

Correct answer: C

Rationale: The MMR vaccine is best administered subcutaneously in the outer aspect of the upper arm. This route allows for proper absorption and efficacy of the vaccine while minimizing the risk of injury or discomfort to the child.

5. A client is receiving desmopressin acetate (DDAVP), and a healthcare provider is monitoring for adverse effects. Which of the following indicates the presence of an adverse effect?

• A. Insomnia
• B. Drowsiness
• C. Weight loss
• D. Increased urination

Correct answer: B

Rationale: Drowsiness can be a sign of water intoxication or hyponatremia, which are potential adverse effects of desmopressin acetate (DDAVP). It is crucial to monitor for this symptom and promptly address it to prevent complications.

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