Nursing Elites

1. A nurse is assessing a client who is receiving IV vancomycin. The nurse notes a flushing of the neck and tachycardia. Which of the following actions should the nurse take?

• A. Document that the client experienced an anaphylactic reaction to the medication.
• B. Change the IV infusion site.
• C. Decrease the infusion rate on the IV.
• D. Apply cold compresses to the neck area.

Correct answer: C

Rationale: Flushing and tachycardia are signs of Red Man Syndrome, which can be mitigated by decreasing the infusion rate.

2. A healthcare provider is reviewing the health history of a client who is starting therapy with tamoxifen. The healthcare provider should recognize that tamoxifen is contraindicated in which of the following clients?

• A. A client with a history of deep-vein thrombosis
• B. A client with a history of migraine headaches
• C. A client with a history of hypertension
• D. A client with a history of anemia

Correct answer: A

Rationale: Tamoxifen is contraindicated in clients with a history of thromboembolic events, such as deep-vein thrombosis, due to the increased risk of blood clots. The estrogenic effects of tamoxifen can further increase the risk of thromboembolic events, making it unsafe for individuals with a history of deep-vein thrombosis. Choice B (migraine headaches), Choice C (hypertension), and Choice D (anemia) are not contraindications for tamoxifen therapy. Migraine headaches, hypertension, and anemia do not pose the same risk of adverse effects related to blood clot formation as deep-vein thrombosis does.

3. A client with HIV is starting therapy with zidovudine. The nurse should monitor the client for which of the following adverse effects of this medication?

• A. Fatigue
• B. Blurred vision
• C. Ringing in the ears
• D. Constipation

Correct answer: A

Rationale: Fatigue is a common adverse effect of zidovudine due to its impact on bone marrow, leading to anemia. Zidovudine is known to cause bone marrow suppression, resulting in decreased production of red blood cells and subsequent fatigue.

4. A client is being discharged with a new prescription for an antihypertensive medication. Which of the following statements should the nurse provide?

• A. Be sure to limit your potassium intake while taking the medication.
• B. You should check your blood pressure every 8 hours while taking this medication.
• C. Your medication dosage will be increased if you develop tachycardia.
• D. Change positions slowly when you move from sitting to standing.

Correct answer: D

Rationale: The correct answer is D. Orthostatic hypotension is a common adverse effect of antihypertensive medications. The client should move slowly to a sitting or standing position and should be taught to sit or lie down if lightheadedness or dizziness occurs. Choices A, B, and C are incorrect. Limiting potassium intake is usually not necessary with antihypertensive medications. Checking blood pressure every 8 hours is not a standard recommendation unless specified by a healthcare provider. Increasing medication dosage due to tachycardia is not a typical practice for antihypertensive medications.

5. A client is receiving treatment with vincristine. Which of the following findings should the nurse monitor?

• A. Hyperkalemia
• B. Neurotoxicity
• C. Neutropenia
• D. Bradycardia

Correct answer: B

Rationale: The correct answer is B: Neurotoxicity. Vincristine is known to cause neurotoxicity as an adverse effect due to its impact on the nervous system. Monitoring for neurotoxicity is crucial to detect any signs early. Choices A, C, and D are incorrect. Hyperkalemia is not a typical finding associated with vincristine. Neutropenia is a common side effect of chemotherapy but is not directly related to vincristine. Bradycardia is not a common adverse effect of vincristine.

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