Nursing Elites

1. A client with thrombophlebitis receiving heparin by continuous IV infusion asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give?

• A. It usually takes heparin at least 2 to 3 days to reach a therapeutic blood level.
• B. A pharmacist is the person to answer that question.
• C. Heparin does not dissolve clots. It stops new clots from forming.
• D. The oral medication you will take after this IV will dissolve the clot.

Correct answer: C

Rationale: The correct response is C. Heparin does not dissolve clots; it prevents new clots from forming. Heparin works by inhibiting the formation of new clots and the extension of existing clots, rather than directly dissolving them. The client should be informed that the purpose of heparin therapy is to prevent the clot from getting larger and to reduce the risk of new clots forming. Choices A, B, and D are incorrect. Choice A talks about reaching a therapeutic blood level of heparin, which is not related to clot dissolution. Choice B deflects the question to a pharmacist without providing relevant information. Choice D inaccurately suggests that an oral medication will dissolve the clot, which is not the mechanism of action for heparin.

2. When educating a client with a new prescription for Losartan, which instruction should the nurse provide?

• A. Avoid consuming grapefruit juice.
• B. Take this medication with a full glass of water.
• C. Take this medication with food.
• D. Monitor for signs of dehydration.

Correct answer: D

Rationale: The correct answer is to instruct the client to monitor for signs of dehydration when taking Losartan. Losartan can lead to dehydration, so it is crucial for the client to watch out for symptoms like dry mouth, increased thirst, and reduced urine output. Monitoring for these signs can help prevent complications associated with dehydration while taking this medication. Choices A, B, and C are incorrect because Losartan is not known to have interactions with grapefruit juice, does not require a specific amount of water for intake, and can be taken with or without food.

3. A client who received Prochlorperazine 4 hours ago reports spasms of his face. The nurse should anticipate a prescription for which of the following medications?

• A. Fomepizole
• B. Naloxone
• C. Phytonadione
• D. Diphenhydramine

Correct answer: D

Rationale: An adverse effect of prochlorperazine is acute dystonia, which is evidenced by spasms of the muscles in the face, neck, and tongue. Diphenhydramine is used to suppress extrapyramidal effects of prochlorperazine, making it the most appropriate choice to address the client's spasms. Fomepizole is used in methanol or ethylene glycol poisoning, not for acute dystonia. Naloxone is an opioid antagonist used for opioid overdose, not for acute dystonia. Phytonadione is vitamin K, used for the reversal of warfarin, not for acute dystonia.

4. Which of the following is commonly used to treat migraine headaches?

• A. Beta-blockers
• B. Cholinesterase Inhibitors
• C. ACE inhibitors
• D. Anti-epileptic drugs (AEDs)

Correct answer: D

Rationale: Anti-epileptic drugs (AEDs) are often used in the management of migraine headaches due to their ability to help prevent or reduce the frequency and intensity of migraines. They work by stabilizing electrical activity in the brain, which can help in controlling migraine symptoms. While beta-blockers are also sometimes used in migraine prevention, anti-epileptic drugs are more commonly associated with migraine treatment. Cholinesterase Inhibitors are not typically used for migraine headaches, as they are more commonly associated with conditions like Alzheimer's disease. ACE inhibitors are a type of medication used to treat conditions like high blood pressure and heart failure, but they are not a first-line treatment for migraines.

5. A client is taking Epoetin Alfa for anemia. Which of the following laboratory tests should the nurse monitor to evaluate the effectiveness of the therapy?

• A. White blood cell count
• B. Platelet count
• C. Hematocrit
• D. Serum potassium level

Correct answer: C

Rationale: The nurse should monitor the hematocrit level to evaluate the effectiveness of Epoetin Alfa therapy since it stimulates red blood cell production. Hematocrit reflects the volume of red blood cells in the blood, providing a direct measure of the therapy's impact on increasing red blood cell mass and addressing anemia. Monitoring white blood cell count and platelet count is not directly related to assessing the effectiveness of Epoetin Alfa therapy for anemia. Serum potassium level monitoring may be necessary due to potential side effects of the medication, but it is not the primary indicator of therapy effectiveness in treating anemia.

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