Nursing Elites

1. A nurse is providing client education regarding lithium therapy. Which of the following instructions should the nurse include?

• A. Take with food to decrease nausea
• B. Avoid excessive intake of caffeinated beverages
• C. Monitor for signs of dehydration
• D. Restrict salt intake to prevent water retention

Correct answer: B

Rationale: The correct answer is B. The nurse should instruct the client to avoid excessive intake of caffeinated beverages as they can interfere with lithium levels. Option A is incorrect as lithium is usually recommended to be taken on an empty stomach. Option C is not directly related to lithium therapy. Option D is not a typical instruction for lithium therapy.

2. A client with an artificial heart valve is prescribed warfarin therapy. Which of the following laboratory values should the nurse monitor to assess the therapeutic effect of warfarin?

• A. Hemoglobin (Hgb)
• B. Prothrombin time (PT)
• C. Bleeding time
• D. Activated partial thromboplastin time (aPTT)

Correct answer: B

Rationale: The correct answer is B: Prothrombin time (PT). Warfarin is an anticoagulant medication that works by inhibiting the clotting factors dependent on vitamin K, such as factors II, VII, IX, and X. The prothrombin time (PT) measures the extrinsic pathway and is used to monitor the therapeutic effects of warfarin therapy. Monitoring PT helps assess the time it takes for the blood to clot, ensuring that the anticoagulant effect is within the desired range. Choices A, C, and D are incorrect because hemoglobin (Hgb) measures the amount of hemoglobin in the blood, bleeding time assesses the time it takes for bleeding to stop, and activated partial thromboplastin time (aPTT) is used to monitor heparin therapy, not warfarin therapy.

3. A nurse is providing client education on how to administer insulin. Which of the following instructions should the nurse include?

• A. Administer the insulin into the deltoid muscle
• B. Rotate injection sites to prevent lipodystrophy
• C. Massage the site after injection
• D. Use the same site for each injection

Correct answer: B

Rationale: The correct instruction for administering insulin is to rotate injection sites to prevent lipodystrophy, a common complication of insulin therapy. Injecting into the deltoid muscle (Choice A) is not recommended for insulin injections. Massaging the site after injection (Choice C) is not necessary and can potentially increase the risk of lipodystrophy. Using the same site for each injection (Choice D) can lead to localized tissue damage and absorption irregularities, making it an incorrect choice.

4. A nurse is caring for a client taking ciprofloxacin for an infection. Which of the following adverse effects should the nurse include in the client education?

• A. Constipation
• B. Tendon rupture
• C. Dry mouth
• D. Nasal congestion

Correct answer: B

Rationale: The correct answer is B: Tendon rupture. Ciprofloxacin belongs to the fluoroquinolone class of antibiotics, which is associated with the adverse effect of tendon rupture. Tendon rupture is a severe but rare side effect that can occur with the use of ciprofloxacin. Educating the client about this potential adverse effect is crucial to promote awareness and early recognition of symptoms, such as tendon pain, swelling, or inflammation. Choices A, C, and D are not typically associated with ciprofloxacin use and are less relevant for client education in this scenario.

5. A nurse is preparing to administer nitroglycerin ointment to a client. Which of the following actions should the nurse take?

• A. Apply the ointment to the client's hairless chest
• B. Rub the ointment gently into the skin
• C. Cover the applied ointment with a transparent dressing
• D. Massage the ointment into the skin

Correct answer: A

Rationale: The correct action is to apply the nitroglycerin ointment to a hairless area of the client's chest, back, or upper arms. This allows for better absorption of the medication. Choice B is incorrect because rubbing the ointment gently into the skin may be appropriate, but the primary action is to ensure application on a hairless area. Choice C is incorrect as covering the ointment with a transparent dressing is not a standard practice for nitroglycerin ointment administration. Choice D is incorrect because massaging the ointment into the skin is not recommended, as it can alter absorption rates.

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