Nursing Elites

1. A client has been prescribed isosorbide mononitrate. Which of the following should the nurse include in the client education related to this medication?

• A. This medication is prescribed for long-term therapy prophylaxis against anginal attacks
• B. Do not crush this medication
• C. Take the medication in the evening after dinner
• D. Do not take an additional tablet if you experience chest pain

Correct answer: A

Rationale: The correct answer is A because isosorbide mononitrate is used for long-term prophylaxis against anginal attacks. Choice B is incorrect because isosorbide mononitrate should not be crushed. Choice C does not specify a particular time for medication administration. Choice D is incorrect because isosorbide mononitrate is not meant to be taken as needed for chest pain; it is part of a long-term therapy plan.

2. A nurse is administering metformin to a client with type 2 diabetes. Which of the following adverse effects should the nurse monitor for in this client?

• A. Diarrhea
• B. Hyperglycemia
• C. Hypoglycemia
• D. Lactic acidosis

Correct answer: D

Rationale: The correct answer is D, Lactic acidosis. Lactic acidosis is a rare but serious adverse effect of metformin use. Metformin is not known to cause hyperglycemia or hypoglycemia. Diarrhea is a common gastrointestinal side effect of metformin but is not as serious as lactic acidosis, which requires immediate medical attention.

3. A nurse is providing care to a client with staphylococcus epidermidis who is prescribed vancomycin. Identify the adverse effect associated with the antibiotic therapy.

• A. Hepatotoxicity
• B. Constipation
• C. Infusion reaction
• D. Immunosuppression

Correct answer: C

Rationale: The correct answer is C: Infusion reaction. Vancomycin can cause infusion reactions like 'Red Man Syndrome,' which involves rashes, flushing, tachycardia, and hypotension. Hepatotoxicity (choice A) is not a common adverse effect of vancomycin. Constipation (choice B) is not typically associated with vancomycin use. Immunosuppression (choice D) is not a direct adverse effect of vancomycin therapy.

4. A nurse is caring for a client prescribed enoxaparin for deep vein thrombosis prophylaxis. Which of the following client assessments requires immediate intervention?

• A. Platelet count of 95,000/mm³
• B. Blood pressure of 145/90 mmHg
• C. Heart rate of 95 beats per minute
• D. Pain at the injection site

Correct answer: A

Rationale: A platelet count of 95,000/mm³ requires immediate intervention as it is low and increases the risk of bleeding, which is a potential complication of enoxaparin therapy. Low platelet counts can predispose the patient to hemorrhage, and administering anticoagulants like enoxaparin in such cases can further increase the bleeding risk. Monitoring platelet counts is crucial during anticoagulant therapy to prevent serious bleeding complications. The other options do not pose immediate risks related to enoxaparin therapy. A slightly elevated blood pressure, a heart rate of 95 beats per minute, and pain at the injection site are common findings that may not warrant immediate intervention in this context.

5. A nurse is preparing to administer an intramuscular injection to an adult client. At what angle should the nurse administer the medication using the ventrogluteal site?

• A. a 45-degree angle
• B. a 60-degree angle
• C. a 75-degree angle
• D. a 90-degree angle

Correct answer: D

Rationale: Intramuscular injections in the ventrogluteal site should be administered at a 90-degree angle. This angle ensures that the medication reaches the muscle tissue effectively. Angles less than 90 degrees can cause subcutaneous injection instead of intramuscular, leading to slower absorption of the medication. Angles greater than 90 degrees risk hitting bone or nerves, causing unnecessary pain or injury. Therefore, the correct angle for administering intramuscular injections in the ventrogluteal site is 90 degrees.

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