Nursing Elites

1. The client is receiving furosemide (Lasix) for heart failure. What potential side effect should the nurse monitor for?

• A. Hypokalemia
• B. Hyperkalemia
• C. Hypernatremia
• D. Hypoglycemia

Correct answer: A

Rationale: The correct answer is A: Hypokalemia. Furosemide, a loop diuretic, causes potassium loss, leading to hypokalemia. Monitoring potassium levels is crucial because hypokalemia can result in cardiac arrhythmias and muscle weakness. Choices B, C, and D are incorrect because furosemide does not typically cause hyperkalemia, hypernatremia, or hypoglycemia.

2. A client has a new prescription for sertraline. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should take this medication at bedtime.
• B. I may experience sexual dysfunction.
• C. I should avoid drinking grapefruit juice.
• D. I may experience weight loss while taking this medication.

Correct answer: B

Rationale: The correct answer is B. Sexual dysfunction is a common side effect of sertraline. When the client mentions this potential side effect, it indicates an understanding of the teaching about the medication's effects. This response shows awareness of a significant adverse effect that the client should be informed about when starting sertraline. Choices A, C, and D are incorrect because taking sertraline at bedtime, avoiding grapefruit juice, or experiencing weight loss are not key teaching points associated with this medication.

3. A client has a new prescription for nitroglycerin. Which of the following instructions should the nurse include in the discharge teaching?

• A. Store the medication in a cool, dark place.
• B. Take the medication at bedtime.
• C. Take the medication on an empty stomach.
• D. Take the medication at the first sign of chest pain.

Correct answer: D

Rationale: The correct instruction to include in the discharge teaching for a client with a new prescription for nitroglycerin is to take the medication at the first sign of chest pain. Nitroglycerin is a vasodilator that helps relax blood vessels, increasing blood flow to the heart muscle and reducing the workload of the heart. Taking it at the onset of chest pain helps alleviate angina symptoms quickly and effectively. Storing the medication in a cool, dark place (Choice A) is not a critical instruction for this medication. Taking the medication at bedtime (Choice B) or on an empty stomach (Choice C) is not relevant to the administration of nitroglycerin for angina relief.

4. The client is receiving heparin therapy for deep vein thrombosis (DVT). Which lab test should be monitored to evaluate the effectiveness of heparin?

• A. Prothrombin time (PT)
• B. International normalized ratio (INR)
• C. Activated partial thromboplastin time (aPTT)
• D. Fibrinogen levels

Correct answer: C

Rationale: Activated partial thromboplastin time (aPTT) is the appropriate lab test to monitor the therapeutic effectiveness of heparin therapy. Heparin affects the intrinsic pathway of the coagulation cascade, and monitoring aPTT helps ensure the client is within the therapeutic range to prevent clot formation. Prothrombin time (PT) and International normalized ratio (INR) are used to monitor warfarin therapy, a different anticoagulant that affects the extrinsic pathway of the coagulation cascade. Fibrinogen levels are not specific to monitoring heparin therapy.

5. When preparing to administer a controlled substance, which of the following actions is required?

• A. Check the client's identification bracelet.
• B. Check the client's allergy status.
• C. Have a second nurse witness disposal of the medication.
• D. Document the administration in the client's medical record.

Correct answer: C

Rationale: When administering controlled substances, it is crucial to have a second nurse witness the disposal of the medication. This measure ensures proper handling, reduces the risk of diversion, and promotes compliance with regulations regarding controlled substances. Having a second nurse witness the disposal is a safeguard to maintain accountability and prevent any potential misuse or errors during the disposal process. Checking the client's identification bracelet and allergy status are important steps in medication administration but are not specifically required for controlled substances. Documenting the administration in the client's medical record is essential but does not specifically relate to the disposal of controlled substances.

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