Nursing Elites

1. A healthcare professional is preparing to administer an IV bolus of Morphine to a client for pain management. Which of the following assessments is the healthcare professional's priority?

• A. Respiratory rate
• B. Pain level
• C. Blood pressure
• D. Level of consciousness

Correct answer: A

Rationale: The priority assessment for a client receiving an IV bolus of Morphine is the respiratory rate. Morphine can cause respiratory depression, which is a serious adverse effect. Monitoring the respiratory rate is crucial to detect any signs of respiratory compromise early and intervene promptly. Assessing pain level, blood pressure, and level of consciousness are also important but not the priority in this situation. Pain level can be assessed after ensuring the client's respiratory status is stable. Blood pressure and level of consciousness should be monitored but do not take precedence over the respiratory rate when administering Morphine.

2. A client with Hodgkin's disease is receiving Cyclophosphamide IV. Which medication should be administered concurrently to prevent an adverse effect of Cyclophosphamide?

• A. Uroprotectant agent, such as mesna
• B. Opioid, such as morphine
• C. Loop diuretic, such as furosemide
• D. H1 receptor antagonist, such as diphenhydramine

Correct answer: A

Rationale: Mesna, an uroprotectant agent, is administered with nitrogen mustard chemotherapy drugs like Cyclophosphamide to prevent hemorrhagic cystitis, a common adverse effect. Mesna works by binding to and inactivating the toxic metabolites of Cyclophosphamide in the bladder, thereby reducing the risk of bladder toxicity.

3. During an assessment, a male client who has recently started taking Haloperidol is displaying certain symptoms. Which of the following findings should the nurse prioritize in reporting to the provider?

• A. Shuffling gait
• B. Neck spasms
• C. Drowsiness
• D. Impotence

Correct answer: B

Rationale: Neck spasms are indicative of acute dystonia, a serious side effect of Haloperidol that requires urgent intervention. Immediate reporting to the provider is crucial to address this potentially harmful condition and ensure the client's safety. Shuffling gait, drowsiness, and impotence are important to monitor but do not pose the same level of immediate risk as acute dystonia. Acute dystonia can lead to serious complications if not promptly treated, making it the priority in this scenario.

4. A client has a prescription for Hydrochlorothiazide. Which of the following instructions should the nurse include?

• A. Take this medication in the morning.
• B. Increase intake of potassium-rich foods.
• C. Take this medication with food.
• D. Monitor for signs of dehydration.

Correct answer: D

Rationale: The correct answer is to monitor for signs of dehydration. Hydrochlorothiazide is a diuretic that can lead to fluid loss and electrolyte imbalance, potentially causing dehydration. Signs of dehydration include dry mouth, increased thirst, and decreased urine output. It is important for the client to be vigilant in monitoring and reporting these symptoms to healthcare providers to prevent complications. Choices A, B, and C are incorrect because taking the medication in the morning, increasing potassium-rich foods, or taking the medication with food are not specific instructions related to the potential side effects of Hydrochlorothiazide.

5. A healthcare professional is reviewing a client's health record and notes that the client experiences permanent extrapyramidal effects caused by a previous medication. The healthcare professional should recognize that the medication affected which of the following systems in the client?

• A. Cardiovascular
• B. Immune
• C. Central nervous
• D. Gastrointestinal

Correct answer: C

Rationale: The correct answer is C: Central nervous. Extrapyramidal effects are movement disorders caused by certain medications affecting the central nervous system. These effects can include symptoms like tremors, rigidity, and bradykinesia. Medications like typical antipsychotics induce extrapyramidal effects by interfering with dopamine transmission in the central nervous system. Choices A, B, and D are incorrect as extrapyramidal effects are specifically related to the central nervous system and not the cardiovascular, immune, or gastrointestinal systems.

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