Nursing Elites

1. A client with a history of coronary artery disease (CAD) is prescribed atorvastatin (Lipitor). The nurse should teach the client about which common side effect of this medication?

• A. Dry mouth
• B. Muscle pain
• C. Drowsiness
• D. Diarrhea

Correct answer: B

Rationale: Muscle pain is a common side effect of statins like atorvastatin. It is important for the nurse to educate the client about this potential side effect, as it can indicate a serious condition called rhabdomyolysis, which requires immediate medical attention. Dry mouth, drowsiness, and diarrhea are not typically associated with atorvastatin use.

2. The nurse is assisting in the care of a client with a history of chronic obstructive pulmonary disease (COPD) who is on oxygen therapy. Which action should the nurse take to ensure the client's safety?

• A. Set the oxygen flow rate to 4 liters per minute.
• B. Remove oxygen while the client is eating.
• C. Ensure the client wears a nasal cannula instead of a face mask.
• D. Maintain the oxygen flow rate at the lowest level that relieves hypoxia.

Correct answer: D

Rationale: For clients with COPD, too much oxygen can suppress their drive to breathe, leading to hypoventilation. Therefore, the nurse should maintain the oxygen flow rate at the lowest level that relieves hypoxia to prevent complications while ensuring adequate oxygenation. Setting the oxygen flow rate too high (Choice A) can be detrimental for the client with COPD. Removing oxygen while the client is eating (Choice B) can compromise oxygenation, which is essential even during meals. While nasal cannulas are commonly used, the choice of oxygen delivery device depends on the client's needs; there may be situations where a face mask (Choice C) is more appropriate.

3. The healthcare provider is preparing to administer a beta blocker to a client with hypertension. What parameter should be checked before administering the medication?

• A. Serum potassium level
• B. Apical pulse
• C. Oxygen saturation
• D. Pupil reaction to light

Correct answer: B

Rationale: Before administering a beta blocker, it is crucial to check the apical pulse. Beta blockers have the potential to slow down the heart rate, making it essential to assess the pulse rate to ensure it is within the safe range before giving the medication. Checking the serum potassium level (choice A) is important when administering certain medications, but it is not specifically required before giving a beta blocker. Oxygen saturation (choice C) and pupil reaction to light (choice D) are not directly related to monitoring parameters for beta blocker administration.

4. The healthcare professional is caring for a client who has just returned from a cardiac catheterization. The healthcare professional should prioritize which assessment?

• A. Monitoring the client's vital signs every 4 hours
• B. Assessing the puncture site for bleeding
• C. Encouraging the client to ambulate early to prevent complications
• D. Providing the client with fluids to flush out the contrast dye

Correct answer: B

Rationale: Assessing the puncture site for bleeding is a critical assessment after a cardiac catheterization procedure. This is essential to detect and address any potential complications promptly, such as hemorrhage or hematoma formation. Monitoring vital signs, encouraging early ambulation, and providing fluids to flush out contrast dye are important aspects of post-cardiac catheterization care, but assessing the puncture site for bleeding takes precedence due to the immediate risk of complications such as severe bleeding that require immediate intervention.

5. A client is receiving heparin therapy. Which of the following laboratory tests should be monitored to evaluate the effectiveness of the therapy?

• A. Prothrombin time (PT)
• B. International normalized ratio (INR)
• C. Activated partial thromboplastin time (aPTT)
• D. Complete blood count (CBC)

Correct answer: C

Rationale: Activated partial thromboplastin time (aPTT) is the most appropriate laboratory test to monitor the effectiveness of heparin therapy. Heparin works on the intrinsic pathway of the coagulation cascade, and monitoring aPTT helps assess its anticoagulant effect. Therapeutic levels of aPTT for clients on heparin therapy are typically 1.5 to 2.5 times the control value. Prothrombin time (PT) and International normalized ratio (INR) are used to monitor warfarin therapy, which acts on the extrinsic pathway of the coagulation cascade. Complete blood count (CBC) is not specific for monitoring the effectiveness of heparin therapy.

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