Nursing Elites

1. A client is prescribed nitroglycerin (Nitro-Dur) transdermal patch for angina. Which instruction should the nurse include in the client's teaching plan?

• A. Apply the patch to a hairless area of skin.
• B. Leave the patch on for 24 hours.
• C. Apply the patch at the same time each day.
• D. You can keep the patch on while taking a shower.

Correct answer: C

Rationale: The correct instruction for the nurse to include in the client's teaching plan is to apply the nitroglycerin (Nitro-Dur) transdermal patch at the same time each day. This consistency helps maintain steady blood levels of the medication. While it is important to apply the patch to a hairless area of the skin for proper absorption, it does not necessarily have to be left on for 24 hours; typically, it is worn for 12-14 hours to allow for a nitrate-free period and reduce tolerance. Additionally, the patch can generally be kept on while taking a shower, as water exposure does not typically affect its efficacy.

2. Oral iron supplements are prescribed for a 6-year-old child with iron deficiency anemia. The nurse instructs the mother to administer the iron with which of the following food items?

• A. Milk
• B. Water
• C. Apple juice
• D. Orange juice

Correct answer: D

Rationale: Iron absorption is enhanced by the presence of vitamin C. Orange juice is a good source of vitamin C, which can improve the absorption of iron when taken together. Therefore, administering iron supplements with orange juice is the best choice to optimize iron absorption for the child.

3. A healthcare professional is monitoring a client who is receiving intravenous amphotericin B. Which of the following should prompt the healthcare professional to notify the healthcare provider immediately?

• A. Fever
• B. Headache
• C. Nausea
• D. Oliguria

Correct answer: D

Rationale: Amphotericin B is known to cause nephrotoxicity, which can lead to kidney damage. Oliguria, which is decreased urine output, is a concerning sign of kidney dysfunction and should be reported promptly to the healthcare provider to prevent further complications. Fever, headache, and nausea are common side effects of amphotericin B but are not as critical as oliguria in indicating potential kidney damage.

4. A client with a prescription to take theophylline (Theo-24) daily has been given medication instructions by the nurse. The nurse determines that the client needs further information about the medication if the client states that he or she will:

• A. Drink at least 2 L of fluid per day.
• B. Take the daily dose at bedtime.
• C. Avoid changing brands of the medication without health care provider (HCP) approval.
• D. Avoid over-the-counter (OTC) cough and cold medications unless approved by the HCP.

Correct answer: B

Rationale: The correct answer is B. Taking theophylline at bedtime is inappropriate because it can cause insomnia. The medication should be taken early in the morning to avoid disrupting sleep patterns. It is important to follow the healthcare provider's instructions regarding the timing of the medication to achieve optimal therapeutic effects.

5. A client is receiving morphine sulfate for pain management. Which assessment finding requires immediate action?

• A. Constipation
• B. Drowsiness
• C. Respiratory rate of 10 breaths per minute
• D. Nausea

Correct answer: C

Rationale: A respiratory rate of 10 breaths per minute indicates respiratory depression, a serious side effect of morphine sulfate that can lead to respiratory compromise and requires immediate intervention. Constipation, drowsiness, and nausea are common side effects of morphine but are not immediately life-threatening compared to respiratory depression. Monitoring and addressing a low respiratory rate are crucial in preventing further respiratory distress or failure.

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