Nursing Elites

1. In a capillary glucose measurement, a client is to receive 10 units of regular insulin and isophane insulin. How should the nurse prepare?

• A. Withdraw ten units of regular insulin from a vial
• B. Withhold the dose until regular insulin is available
• C. Obtain a new vial of regular insulin and withhold
• D. Pull up 30 units from a vial but only administer 10 units

Correct answer: B

Rationale: In insulin administration, regular insulin is typically administered before isophane insulin to manage blood glucose effectively. If regular insulin is not available, it is best to withhold the dose until it can be administered as prescribed. Choice A is incorrect as it suggests withdrawing from a specific vial without specifying regular insulin. Choice C is incorrect as obtaining a new vial of regular insulin may not be necessary if it becomes available shortly. Choice D is incorrect as administering 10 units from a mixture of regular and isophane insulin is not the correct approach.

2. A client with a diagnosis of schizophrenia is prescribed olanzapine. The nurse should monitor for which potential side effect?

• A. Weight gain
• B. Insomnia
• C. Dry mouth
• D. Headache

Correct answer: A

Rationale: When a client with schizophrenia is prescribed olanzapine, the nurse should monitor for weight gain as a potential side effect. Olanzapine is known to cause metabolic changes that can lead to weight gain, making it crucial for the nurse to closely monitor the client's weight during treatment. This side effect is significant as it can impact the client's overall health and well-being, so early detection and intervention are essential to manage it effectively.

3. A client with a history of deep vein thrombosis is prescribed warfarin. The nurse should monitor for which potential adverse effect?

• A. Increased risk of bleeding
• B. Decreased risk of bleeding
• C. Increased risk of infection
• D. Decreased risk of infection

Correct answer: A

Rationale: The correct answer is A: Increased risk of bleeding. Warfarin is an anticoagulant medication that works by prolonging the time it takes for blood to clot. Therefore, a potential adverse effect of warfarin is an increased risk of bleeding. It is crucial for the nurse to monitor the client for signs of bleeding, such as easy bruising, prolonged bleeding from cuts, nosebleeds, or blood in the urine or stool. Monitoring for these signs is essential to prevent serious complications associated with excessive bleeding. Choices B, C, and D are incorrect because warfarin does not decrease the risk of bleeding, increase the risk of infection, or decrease the risk of infection. The primary concern with warfarin therapy is the potential for bleeding complications, so close monitoring for signs of bleeding is essential.

4. A client with an exacerbation of asthma is prescribed albuterol. The nurse should assess the client for which common side effect of this medication?

• A. Tremors
• B. Nausea and vomiting
• C. Insomnia
• D. Dry mouth

Correct answer: A

Rationale: The correct answer is A: Tremors. Albuterol, a beta-agonist medication commonly used to treat asthma exacerbations, can lead to tremors as a side effect. Tremors result from the stimulation of beta-2 receptors in muscles, particularly in the hands. Nausea and vomiting (Choice B) are generally not common side effects of albuterol. Insomnia (Choice C) is less likely to occur with albuterol, as it is a stimulant and can cause alertness rather than sleep disturbances. Dry mouth (Choice D) is not a typical side effect associated with albuterol use.

5. A client who is obtunded arrives in the emergency center with a suspected drug overdose. Intravenous naloxone is given, but within a short period, the client's level of consciousness deteriorates. What action should the nurse take first?

• A. Initiate a second intravenous access site
• B. Prepare to initiate cardiopulmonary resuscitation
• C. Determine the results of the drug toxicity screen
• D. Administer an additional dose of naloxone

Correct answer: D

Rationale: Administering an additional dose of naloxone should be the first action taken by the nurse in this scenario. Naloxone is an opioid antagonist used to reverse the effects of opioid overdose. If the client's level of consciousness deteriorates after the initial dose, administering another dose can help further reverse the overdose effects and improve the client's condition. Once the additional naloxone dose is given, the nurse can then proceed to assess the client's response and consider other interventions as needed.

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