Nursing Elites

1. During an admission assessment for a client with severe Aspirin toxicity, what finding should the nurse expect?

• A. Body temperature 35°C (95°F)
• B. Lung crackles
• C. Cool, dry skin
• D. Respiratory depression

Correct answer: D

Rationale: In severe Aspirin toxicity, respiratory depression can occur due to increasing respiratory acidosis. Aspirin toxicity leads to metabolic acidosis, stimulating the respiratory center in the brain to increase the respiratory rate initially. However, as the toxicity worsens, respiratory muscle fatigue and depression can occur, resulting in respiratory depression. This can lead to hypoxia, respiratory failure, and ultimately, respiratory arrest.

2. A client with a prescription for Vasopressin to treat Diabetes Insipidus is being taught by a healthcare professional. Which of the following client statements indicates an understanding of the teaching?

• A. I will reduce my sodium intake.
• B. I should increase my water intake.
• C. I will notify my doctor if I develop chest pain.
• D. I should take this medication with food.

Correct answer: C

Rationale: The correct answer is C because Vasopressin can cause vasoconstriction, potentially leading to chest pain. It is crucial for the client to inform their healthcare provider immediately if they experience chest pain while on Vasopressin therapy to address any potential cardiovascular complications promptly. Choices A, B, and D are incorrect. While maintaining adequate hydration is essential with Vasopressin therapy due to its antidiuretic effect, increasing water intake is not the most critical aspect to monitor. Reducing sodium intake may be beneficial in some cases but is not directly related to the potential side effects of Vasopressin. Taking the medication with food is not a specific instruction for Vasopressin administration.

3. A client with Angina Pectoris asks the nurse about the next step if one tablet does not relieve Anginal pain after waiting 5 minutes. Which of the following responses should the nurse make?

• A. Take two more sublingual tablets simultaneously.
• B. Call emergency services.
• C. Take a sustained-release nitroglycerin capsule.
• D. Wait another 5 minutes before taking a second sublingual tablet.

Correct answer: B

Rationale: In a situation where Anginal pain persists after taking one sublingual tablet and waiting 5 minutes, it is crucial to call emergency services (911) immediately. This could indicate a myocardial infarction (heart attack) rather than a typical Anginal attack. The client should not take two more sublingual tablets simultaneously without seeking immediate medical help as this could delay appropriate intervention if the pain is due to a heart attack. Taking a sustained-release nitroglycerin capsule is not recommended for immediate relief of acute Anginal pain as it works too slowly. Waiting another 5 minutes before taking a second sublingual tablet is not appropriate if the pain persists, as prompt action is essential in suspected heart-related issues.

4. When teaching parents about a child newly prescribed Desipramine, the nurse should instruct them that which of the following adverse effects is the priority to report to the provider?

• A. Constipation
• B. Suicidal thoughts
• C. Photophobia
• D. Dry mouth

Correct answer: B

Rationale: The priority adverse effect to report when a child is prescribed Desipramine is suicidal thoughts. Desipramine can increase the risk of suicidal thoughts and behaviors. It is crucial for parents to monitor the child for any signs of worsening depression or thoughts of self-harm and report them promptly to the healthcare provider to prevent any harm to the child. Options A, C, and D are potential side effects of Desipramine but are not as urgent or life-threatening as suicidal thoughts, which require immediate intervention to ensure the safety of the child.

5. A client is starting therapy with Metformin. Which of the following instructions should the nurse include?

• A. Take this medication with your first bite of food.
• B. Take this medication on an empty stomach.
• C. Take this medication before bedtime.
• D. Take this medication every other day.

Correct answer: A

Rationale: Metformin should be taken with meals to reduce gastrointestinal side effects and ensure better absorption. Instructing the client to take the medication with the first bite of food helps in achieving optimal effectiveness and minimizes the risk of side effects like nausea or upset stomach. Choice B is incorrect because taking Metformin on an empty stomach can lead to increased gastrointestinal side effects. Choice C is incorrect as there is no specific timing requirement for taking Metformin before bedtime. Choice D is incorrect as Metformin is usually taken daily, not every other day.

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