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. Which action should be taken to assess for analgesic tolerance in a client who is unable to communicate?

• A. Review the client's laboratory values for changes in peak and trough levels of the analgesic
• B. Prolong the interval between analgesic medication doses and monitor the client's vital signs
• C. Observe the client for the presence of pain behaviors before the next analgesic dose is due
• D. Ask family members to report behaviors suggesting that the client's pain has returned

Correct answer: C

Rationale: In clients who are unable to communicate, observing for pain behaviors is crucial in assessing analgesic tolerance. Changes in pain behaviors can indicate if the current analgesic regimen is effective or if tolerance has developed. Therefore, closely observing the client for pain behaviors before the next analgesic dose helps healthcare providers evaluate the client's response to pain management. Reviewing laboratory values may not directly reflect analgesic tolerance. Prolonging the interval between doses and monitoring vital signs may not provide direct information on analgesic tolerance. Relying solely on family members to report pain behaviors may not be as accurate or immediate as observing the client directly.

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

• A. Weight gain
• B. Dry mouth
• C. Hair loss
• D. Headache

Correct answer: A

Rationale: The correct answer is A: Weight gain. Olanzapine is known to cause weight gain as a common side effect. This weight gain can increase the risk of metabolic issues such as diabetes and dyslipidemia. Monitoring the client's weight regularly is essential to detect and address any weight changes promptly.

4. A client with gastroesophageal reflux disease (GERD) is prescribed omeprazole. The nurse should reinforce which instruction?

• A. Take this medication in the morning before breakfast.
• B. Take this medication with meals.
• C. Avoid taking this medication with antacids.
• D. Take this medication at bedtime.

Correct answer: A

Rationale: The correct instruction for a client with GERD prescribed omeprazole is to take the medication in the morning before breakfast. Omeprazole works best when taken on an empty stomach, approximately 30 minutes before the first meal of the day. This timing maximizes its effectiveness in reducing stomach acid production and helps manage symptoms of GERD more efficiently. Choice B is incorrect because taking omeprazole with meals may reduce its efficacy as it needs an empty stomach for optimal absorption. Choice C is incorrect because omeprazole can be taken with or without food, but it should not be taken with antacids as they can affect its absorption. Choice D is incorrect because taking omeprazole at bedtime is less effective compared to taking it before breakfast due to the circadian rhythm of gastric acid secretion.

5. A client with a diagnosis of bipolar disorder is prescribed valproate. The nurse should monitor for which potential adverse effect?

• A. Weight gain
• B. Hair loss
• C. Hyperglycemia
• D. Hypoglycemia

Correct answer: A

Rationale: The correct answer is A: Weight gain. Valproate is known to cause weight gain as a common adverse effect. It is important for the nurse to monitor the client's weight regularly while on this medication to detect and address any changes that may occur.

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