Nursing Elites

1. A nurse is caring for a client who has heart failure and is receiving furosemide. Which of the following findings should the nurse identify as an adverse effect of the medication?

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

Correct answer: C

Rationale: The correct answer is C: 'Hypokalemia.' Furosemide is a loop diuretic that can lead to potassium depletion (hypokalemia) due to increased urinary excretion of potassium. This can result in adverse effects such as muscle weakness, cardiac dysrhythmias, and other complications. Hyperkalemia (choice A) is not an adverse effect of furosemide but rather an elevated potassium level. Hyperglycemia (choice B) and hyponatremia (choice D) are not typically associated with furosemide use. Therefore, monitoring potassium levels and addressing hypokalemia is crucial in clients taking furosemide.

2. A client is being taught how to perform self-catheterization. Which of the following instructions should the nurse include?

• A. Clean the catheter with alcohol after each use.
• B. Perform self-catheterization while sitting on the toilet.
• C. Use a new catheter each time you perform self-catheterization.
• D. Lubricate the catheter tip with petroleum jelly before insertion.

Correct answer: C

Rationale: The correct answer is C: 'Use a new catheter each time you perform self-catheterization.' It is essential to use a new, sterile catheter each time to prevent infection during the procedure. Choice A is incorrect because cleaning the catheter with alcohol may not be sufficient to prevent infection. Choice B is incorrect because self-catheterization is typically done in a clean, private area, not necessarily on the toilet. Choice D is incorrect because lubricating the catheter tip with petroleum jelly is a common practice but not as crucial as using a new catheter each time to prevent infection.

3. A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make?

• A. Taking furosemide can cause your potassium levels to be high
• B. Eat foods that are high in sodium
• C. Rise slowly when getting out of bed
• D. Taking furosemide can cause you to be overhydrated

Correct answer: C

Rationale: Furosemide can cause low potassium levels, and clients should be advised to rise slowly to prevent dizziness.

4. A nurse is preparing to mix NPH and regular insulin in the same syringe. Which of the following actions should the nurse take?

• A. Inject air into the NPH insulin vial.
• B. Withdraw the prescribed dose of regular insulin.
• C. Withdraw the prescribed dose of NPH insulin.
• D. Mix the two insulins in separate syringes.

Correct answer: A

Rationale: When mixing NPH and regular insulin in the same syringe, the nurse should first inject air into the NPH insulin vial. This action prevents contamination by allowing an easier withdrawal of the correct dose of NPH insulin after withdrawing the regular insulin. Withdrawing the prescribed dose of regular insulin (Choice B) is incorrect as it does not address the initial step of injecting air into the NPH vial. Similarly, withdrawing the prescribed dose of NPH insulin (Choice C) is incorrect as it skips the crucial first step. Mixing the two insulins in separate syringes (Choice D) is not ideal since combining them in one syringe is a common practice to reduce the number of injections for the patient.

5. A nurse is planning care for a client who has a new prescription for warfarin. Which of the following laboratory values should the nurse monitor to determine the effectiveness of the therapy?

• A. Serum calcium level
• B. Platelet count
• C. INR
• D. WBC count

Correct answer: C

Rationale: Corrected Rationale: The nurse should monitor the client's INR to determine the effectiveness of warfarin therapy. INR monitoring is crucial as it reflects the blood's ability to clot properly. Warfarin is commonly used as an anticoagulant, and maintaining the INR within the therapeutic range ensures that the client is protected from both clotting and bleeding events. Monitoring serum calcium levels, platelet count, or WBC count is not directly related to assessing the effectiveness of warfarin therapy.

Similar Questions