Nursing Elites

1. Which nursing intervention is most important when caring for a client receiving aspirin 600mg po QID?

• A. Monitor temperature q4h
• B. Use 10-point pain scale to assess pain
• C. Assess for dyspepsia and nausea
• D. Check stool for occult blood

Correct answer: D

Rationale: The correct answer is to check the stool for occult blood when caring for a client receiving aspirin 600mg po QID. Aspirin can lead to gastrointestinal bleeding, and checking for occult blood in the stool is essential to monitor for this serious adverse effect. Monitoring temperature, assessing pain, and checking for dyspepsia and nausea are important interventions but not as critical as monitoring for gastrointestinal bleeding when a client is receiving aspirin.

2. A client with a history of atrial fibrillation is prescribed digoxin. The nurse should monitor for which potential side effect?

• A. Bradycardia
• B. Tachycardia
• C. Headache
• D. Hyperglycemia

Correct answer: A

Rationale: The correct answer is A: Bradycardia. Digoxin can lead to bradycardia due to its effect on slowing down the heart rate, which can be dangerous in a client with atrial fibrillation. Monitoring the client's heart rate is essential to detect and manage this potential side effect. Choices B, C, and D are incorrect because digoxin is not known to cause tachycardia, headache, or hyperglycemia as common side effects.

3. A client is prescribed phenobarbital 100 mg daily for the treatment of seizures. Which statement made by the client indicates an accurate understanding of the medication phenobarbital?

• A. I will take my medicine at 10 PM before retiring to bed.
• B. The medication will turn the color of my urine to a pink color.
• C. I should not eat or drink anything for at least 2 hours before taking my medicine.
• D. In the event a seizure occurs in the middle of the day, I need to take an extra dose of my medicine.

Correct answer: A

Rationale: The correct answer is A. Phenobarbital should be taken at the same time every day to maintain blood levels and enhance compliance. Common side effects of phenobarbital include drowsiness, lethargy, dizziness, and nausea; therefore, it is best to take it before bedtime to minimize these effects and improve sleep quality. Choice B is incorrect because phenobarbital does not affect the color of urine. Choice C is incorrect because there is no need to fast before taking phenobarbital. Choice D is incorrect because taking extra doses without healthcare provider guidance can lead to overdose and adverse effects.

4. A client with schizophrenia is prescribed risperidone. Which statement by the client indicates the need for further teaching?

• A. I can stop taking this medication once I feel better.
• B. This medication may cause drowsiness.
• C. This medication might make me feel drowsy.
• D. I should avoid alcohol while taking this medication.

Correct answer: A

Rationale: Clients should not stop taking risperidone abruptly once they feel better without consulting their healthcare provider.

5. A client diagnosed with a herniated disc is prescribed hydrocodone/acetaminophen 10 mg/300 mg prn every 4 to 6 hours. As the practical nurse (PN) enters the client's room to administer the requested medication, the client is seen talking and laughing with visiting family. What action should the PN take?

• A. Hold the pain medication until after the visitors leave.
• B. Notify the healthcare provider of the client's drug-seeking behavior.
• C. Administer analgesia as requested by the client.
• D. Inform the client that the medication is not needed based on their behavior.

Correct answer: C

Rationale: The correct action for the PN in this situation is to administer the analgesia as requested by the client. Pain management is based on the client's self-report of pain, which is the most reliable indicator of pain intensity. Analgesics should be given promptly when pain occurs and before it worsens. Following the administration of medication, the PN should discuss the situation with the charge nurse for further guidance or assessment.

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