Nursing Elites

1. When caring for a client with a wound infection, which action should the nurse perform first in the plan of care?

• A. Administer antibiotic medication.
• B. Obtain a wound specimen for culture.
• C. Review WBC laboratory findings.
• D. Apply a dressing to the wound.

Correct answer: B

Rationale: The priority action when caring for a client with a wound infection is to obtain a wound specimen for culture before initiating antibiotic therapy. This step is crucial to identify the specific microorganism causing the infection, allowing for targeted antibiotic treatment. Reviewing WBC laboratory findings and applying a wound dressing are important steps, but obtaining a wound specimen for culture takes precedence as it guides appropriate antibiotic therapy by identifying the causative organism.

2. A client has a new prescription for Diltiazem. Which of the following statements should the nurse include in the teaching?

• A. This medication may cause dry mouth.
• B. You should avoid drinking grapefruit juice.
• C. You may experience a rapid heart rate.
• D. Increase your intake of fiber-rich foods.

Correct answer: B

Rationale: The correct statement to include when teaching a client about Diltiazem is to avoid drinking grapefruit juice. Grapefruit juice can increase the levels of diltiazem in the blood, leading to potential toxicity and increased side effects. It is important for the client to be aware of this interaction to ensure the safe and effective use of the medication. Option A is incorrect because dry mouth is not a common side effect of Diltiazem. Option C is incorrect because Diltiazem is actually used to treat rapid heart rates. Option D is unrelated to the medication and not relevant to the teaching.

3. A client has a new prescription for Hydralazine. Which of the following side effects should the nurse instruct the client to monitor for and report?

• A. Orthostatic hypotension
• B. Increased heart rate
• C. Dark-colored urine
• D. Persistent cough

Correct answer: B

Rationale: Corrected Rationale: Hydralazine, a vasodilator, can cause reflex tachycardia, leading to an increased heart rate. This side effect should be reported to the healthcare provider to ensure appropriate management and monitoring of the client's condition. Choice A (Orthostatic hypotension) is incorrect as Hydralazine is more likely to cause reflex tachycardia than orthostatic hypotension. Choice C (Dark-colored urine) and Choice D (Persistent cough) are unrelated to the common side effects of Hydralazine and should not be the focus of monitoring for this medication.

4. A client has a prescription for Timolol eye drops for the treatment of glaucoma. Which of the following instructions should the nurse include?

• A. Apply gentle pressure to the nasolacrimal duct for 30 to 60 seconds after application.
• B. Avoid blinking immediately after instilling the drops.
• C. Keep your eyes closed for 5 minutes after application.
• D. Administer the drops directly onto the cornea.

Correct answer: A

Rationale: The correct instruction for the nurse to include is to apply gentle pressure to the nasolacrimal duct for 30 to 60 seconds after application. This technique helps prevent systemic absorption of the medication, reducing the risk of systemic side effects. By applying pressure, the drainage of the medication into the bloodstream through the nasolacrimal duct is minimized, enhancing the drug's local ocular effects. Choices B, C, and D are incorrect because blinking immediately after instilling the drops, keeping eyes closed for 5 minutes, and administering the drops directly onto the cornea are not recommended practices for administering Timolol eye drops.

5. A client has a new prescription for Losartan. Which of the following client statements indicates an understanding of the teaching?

• A. I will increase my intake of potassium-rich foods.
• B. I will take the medication with a full glass of milk.
• C. I should monitor my blood pressure weekly.
• D. I will take the medication every other day.

Correct answer: C

Rationale: The correct answer is C: 'I should monitor my blood pressure weekly.' Monitoring blood pressure regularly is crucial for clients taking Losartan, an angiotensin II receptor blocker, to ensure effective management of hypertension. This medication works to dilate blood vessels, lowering blood pressure, so monitoring is essential to assess its effectiveness. Choices A, B, and D are incorrect because increasing potassium-rich foods can be harmful due to the potassium-sparing effect of Losartan, taking the medication with milk is not recommended, and adherence to the prescribed daily dosing schedule is necessary for optimal therapeutic outcomes.

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