Nursing Elites

1. A client is receiving Morphine IV for pain management. Which of the following actions should the nurse take?

• A. Monitor the client's respiratory rate every 15 minutes.
• B. Monitor the client's blood pressure every 30 minutes.
• C. Monitor the client's oxygen saturation every hour.
• D. Monitor the client's heart rate every 5 minutes.

Correct answer: A

Rationale: The correct action for the nurse is to monitor the client's respiratory rate every 15 minutes while on Morphine IV to promptly detect respiratory depression, a critical adverse effect associated with this medication. Respiratory depression is a common side effect of opioid medications like Morphine and can be life-threatening. Monitoring the respiratory rate frequently enables the nurse to identify early signs of respiratory compromise and intervene promptly. Monitoring other vital signs like blood pressure, oxygen saturation, or heart rate is important but not as crucial as monitoring respiratory rate when a client is on Morphine IV.

2. A client is taking Warfarin for atrial fibrillation. Which of the following client statements indicates a need for further teaching?

• A. I will avoid eating broccoli.
• B. I will use an electric razor to shave.
• C. I will take aspirin for headaches.
• D. I will have my blood tested regularly.

Correct answer: C

Rationale: The correct answer is C. Taking aspirin along with Warfarin can increase the risk of bleeding. Clients should be advised to avoid medications that increase the risk of bleeding when taking Warfarin to prevent complications. Choices A, B, and D are all correct statements indicating good understanding of Warfarin therapy. Avoiding foods high in Vitamin K, using an electric razor to prevent cuts that can lead to bleeding, and regular blood testing to monitor Warfarin levels are all important aspects of managing Warfarin therapy.

3. A toddler is being admitted to the hospital after an Acetaminophen overdose. Which of the following medications should the nurse anticipate administering to this patient?

• A. Acetylcysteine
• B. Pegfilgrastim
• C. Misoprostol
• D. Naltrexone

Correct answer: A

Rationale: In cases of Acetaminophen overdose, acetylcysteine is the antidote of choice. Acetylcysteine helps prevent liver damage by replenishing depleted glutathione levels, which is essential for detoxifying acetaminophen metabolites. Pegfilgrastim is a medication used to stimulate white blood cell production, Misoprostol is a medication for preventing stomach ulcers, and Naltrexone is used for treating opioid addiction and alcoholism, but none of these are indicated for Acetaminophen overdose.

4. What is the therapeutic use of metformin?

• A. Lower blood pressure
• B. Diminish seizure activity
• C. The maintenance of a person's blood glucose levels
• D. Increase heart rate and decrease gastrointestinal secretions

Correct answer: C

Rationale: Metformin is commonly prescribed to manage and control blood glucose levels in individuals with diabetes. It helps in reducing the amount of glucose produced by the liver and improves the body's response to insulin, thereby aiding in the regulation of blood sugar levels. It is not used to lower blood pressure, diminish seizure activity, increase heart rate, or decrease gastrointestinal secretions.

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

• A. Avoid drinking grapefruit juice.
• B. Take this medication with a full glass of water.
• C. Take this medication on an empty stomach.
• D. Monitor for signs of dehydration.

Correct answer: D

Rationale: The correct instruction for a client prescribed Losartan is to monitor for signs of dehydration. Losartan can lead to dehydration, so it is essential for the client to be vigilant for symptoms such as dry mouth, increased thirst, and decreased urine output. Providing the instruction to monitor for signs of dehydration ensures the client's safety and helps in early identification of any potential issues related to dehydration. Choices A, B, and C are incorrect as Losartan does not interact with grapefruit juice, does not require specific instructions regarding water intake, and does not need to be taken on an empty stomach.

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