Nursing Elites

1. A healthcare professional is preparing to administer Diltiazem IV to a client who has atrial fibrillation. Which of the following findings should the healthcare professional report immediately?

• A. Bradycardia.
• B. Hypertension.
• C. Shortness of breath.
• D. Tachycardia.

Correct answer: A

Rationale: The correct answer is bradycardia. Diltiazem, a calcium channel blocker, can lead to bradycardia as a side effect. Bradycardia should be reported immediately because it can result in serious cardiac complications, especially in a client with atrial fibrillation. Hypertension, shortness of breath, and tachycardia are not typically associated with Diltiazem administration and would not be immediate concerns in this scenario.

2. When instructing a client with a new prescription for Timolol on how to insert eye drops, which area should the nurse instruct the client to press on to prevent systemic absorption of the medication?

• A. Bony orbit
• B. Nasolacrimal duct
• C. Conjunctival sac
• D. Outer canthus

Correct answer: B

Rationale: Pressing on the nasolacrimal duct, located near the inner corner of the eye, blocks the lacrimal punctum and prevents the medication from entering the systemic circulation. This technique helps to ensure the medication stays localized in the eye, enhancing its therapeutic effect while minimizing systemic side effects. Choices A, C, and D are incorrect. The bony orbit is the eye socket and not a site to press for preventing systemic absorption. The conjunctival sac is where eye drops are instilled, not pressed on. The outer canthus is also not the correct area to press to prevent systemic absorption.

3. When preparing to administer IV Acyclovir for Herpes Zoster, what action should the nurse take?

• A. Infuse the medication over 1 hour.
• B. Monitor the client's blood pressure every 15 minutes during infusion.
• C. Administer a stool softener.
• D. Monitor the client's blood glucose level every 4 hours during infusion.

Correct answer: A

Rationale: The correct action for the nurse is to infuse IV Acyclovir over at least 1 hour to prevent nephrotoxicity. Rapid infusion can lead to adverse effects, so a slow infusion rate is crucial for patient safety. Monitoring blood pressure, administering a stool softener, or monitoring blood glucose levels are not directly related to the administration of IV Acyclovir for Herpes Zoster.

4. A client's plasma Lithium level is 2.1 mEq/L. Which of the following is an appropriate action by the nurse?

• A. Perform immediate gastric lavage.
• B. Prepare the client for hemodialysis.
• C. Administer an additional oral dose of lithium.
• D. Request a stat repeat of the laboratory test.

Correct answer: A

Rationale: In a client with a plasma lithium level of 2.1 mEq/L, immediate gastric lavage is appropriate for severe toxicity. Gastric lavage can help lower the client's lithium level by removing the unabsorbed lithium from the stomach.

5. Before administering lithium to a client with bipolar disorder who has been taking the medication for 1 year, the nurse should check to see that which of the following tests has been completed?

• A. Thyroid hormone assay
• B. Liver function tests
• C. Erythrocyte sedimentation rate
• D. Brain natriuretic peptide

Correct answer: A

Rationale: The correct answer is to check the thyroid hormone assay. Long-term lithium use can result in thyroid dysfunction, making it crucial to monitor the client's thyroid function regularly to detect any abnormalities early and prevent potential complications. Liver function tests (choice B) are not specifically associated with lithium therapy. Erythrocyte sedimentation rate (choice C) is a nonspecific test for inflammation and not directly related to lithium therapy. Brain natriuretic peptide (choice D) is a test used to diagnose heart failure and is not relevant to monitoring lithium therapy.

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