Nursing Elites

1. A client who has a new prescription for lithium is receiving discharge teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I will need to have my blood levels checked regularly while taking this medication.
• B. I should take this medication on an empty stomach.
• C. I should avoid eating foods that are high in sodium.
• D. I should stop taking this medication if I experience nausea.

Correct answer: A

Rationale: The correct answer is A. Clients prescribed lithium need regular monitoring of blood levels to ensure the medication's effectiveness and safety. This monitoring helps to keep the medication within the therapeutic range and prevent toxicity. Choice B is incorrect because lithium is usually taken with food to minimize gastrointestinal side effects. Choice C is not directly related to lithium therapy; however, excessive sodium intake can affect lithium levels. Choice D is incorrect as abruptly stopping lithium can lead to adverse effects and should only be done under healthcare provider guidance.

2. A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following actions should the nurse take?

• A. Administer 0.9% sodium chloride IV
• B. Administer a hypotonic IV solution
• C. Encourage oral fluid intake
• D. Restrict oral fluid intake

Correct answer: A

Rationale: In a client with a sodium level of 125 mEq/L (hyponatremia), the nurse should administer 0.9% sodium chloride IV to help increase sodium levels. Choice B, administering a hypotonic IV solution, would further decrease the sodium level. Choice C, encouraging oral fluid intake, is contraindicated as it can dilute the sodium concentration further. Choice D, restricting oral fluid intake, could worsen the client's condition by leading to dehydration and further electrolyte imbalances.

3. How should fluid overload in a patient with heart failure be managed?

• A. Administer diuretics
• B. Increase fluid intake
• C. Provide oral fluids
• D. Provide chest physiotherapy

Correct answer: A

Rationale: Administering diuretics is the appropriate management for fluid overload in a patient with heart failure. Diuretics help to reduce fluid retention by increasing urine output, thereby alleviating the fluid overload. Choices B, C, and D are incorrect. Increasing fluid intake would worsen the condition by adding more fluid to an already overloaded system. Providing oral fluids is not specific enough to address the excess fluid in the body, and chest physiotherapy is not indicated for managing fluid overload in heart failure patients.

4. A nurse is caring for a client who has a prescription for enoxaparin. Which of the following actions should the nurse take?

• A. Inject the medication into the deltoid muscle
• B. Inject the medication deep into subcutaneous tissue
• C. Massage the injection site for 2 minutes after administration
• D. Insert the needle at a 10-degree angle

Correct answer: B

Rationale: The correct action the nurse should take when administering enoxaparin is to inject the medication deep into subcutaneous tissue. This method helps ensure proper absorption of the medication and prevents tissue irritation. Injecting into the deltoid muscle (Choice A) is not recommended for enoxaparin administration. Massaging the injection site (Choice C) can lead to tissue damage and bruising. Inserting the needle at a 10-degree angle (Choice D) is not the correct technique for administering enoxaparin.

5. A nurse is caring 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 medication?

• A. Hemoglobin
• B. Platelet count
• C. Prothrombin time (PT)
• D. International normalized ratio (INR)

Correct answer: D

Rationale: The correct answer is D, International normalized ratio (INR). INR is used to monitor the therapeutic effect of warfarin, an anticoagulant medication. Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors. Monitoring the INR helps assess how well the medication is working to prevent blood clots. Choices A, B, and C are not specific indicators for monitoring the effectiveness of warfarin. Hemoglobin levels primarily assess the oxygen-carrying capacity of red blood cells, platelet count evaluates the clotting ability of blood, and PT measures the time it takes for blood to clot. While these values are important for overall health assessment, they do not directly reflect the anticoagulant effects of warfarin.

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