Nursing Elites

1. A client is starting therapy with bicalutamide. Which of the following adverse effects should the nurse instruct the client to monitor?

• A. Muscle pain
• B. Flushing
• C. Gynecomastia
• D. Hyperglycemia

Correct answer: C

Rationale: The correct answer is gynecomastia (Choice C). Bicalutamide is associated with gynecomastia due to its antiandrogenic properties. Gynecomastia, the development of breast tissue in males, is an important adverse effect to monitor when taking bicalutamide. Choices A, B, and D are incorrect. Muscle pain and flushing are not commonly associated with bicalutamide use. Hyperglycemia is not a typical adverse effect of bicalutamide therapy.

2. A client has a new prescription for Alteplase. Which of the following actions should the nurse plan to take?

• A. Administer the medication within 4 hours of the onset of symptoms.
• B. Reconstitute the medication with sterile saline.
• C. Administer heparin concurrently with the Alteplase infusion.
• D. Monitor for changes in level of consciousness.

Correct answer: D

Rationale: Alteplase is a thrombolytic agent used to dissolve blood clots. Patients receiving Alteplase are at risk for bleeding complications, including intracranial bleeding. Monitoring for changes in the level of consciousness is crucial as it can indicate early signs of bleeding, such as increased intracranial pressure. This rapid assessment allows for timely intervention and prevention of further complications. Choices A, B, and C are incorrect. Administering Alteplase within 4 hours of symptom onset is related to the time-sensitive nature of thrombolytic therapy for conditions like acute myocardial infarction or ischemic stroke. Reconstituting Alteplase with sterile saline is a correct step in preparing the medication for administration. Administering heparin concurrently with Alteplase is generally avoided due to the increased risk of bleeding.

3. A client is receiving Morphine IV for pain management. Which of the following actions should the nurse take?

• A. Monitor the client's respiratory rate every 15 minutes.
• B. Monitor the client's blood pressure every 30 minutes.
• C. Monitor the client's oxygen saturation every hour.
• D. Monitor the client's heart rate every 5 minutes.

Correct answer: A

Rationale: The correct action for the nurse is to monitor the client's respiratory rate every 15 minutes while on Morphine IV to promptly detect respiratory depression, a critical adverse effect associated with this medication. Respiratory depression is a common side effect of opioid medications like Morphine and can be life-threatening. Monitoring the respiratory rate frequently enables the nurse to identify early signs of respiratory compromise and intervene promptly. Monitoring other vital signs like blood pressure, oxygen saturation, or heart rate is important but not as crucial as monitoring respiratory rate when a client is on Morphine IV.

4. A client has a new prescription for Metformin. Which of the following instructions should be included?

• A. Take this medication with food.
• B. Avoid eating foods high in potassium.
• C. Take this medication at bedtime.
• D. Take this medication every other day.

Correct answer: A

Rationale: The correct instruction for taking Metformin is to take it with food. This helps reduce gastrointestinal side effects and ensures better absorption of the medication. Choice B is incorrect as there is no specific need to avoid foods high in potassium when taking Metformin. Choice C is incorrect because Metformin is usually taken with meals, not at bedtime. Choice D is incorrect as Metformin is typically taken daily, not every other day.

5. A client has been taking Phenylephrine nasal drops for the past 10 days for Sinusitis. The nurse should assess the client for which of the following adverse effects of this medication?

• A. Sedation
• B. Nasal congestion
• C. Productive cough
• D. Constipation

Correct answer: B

Rationale: The correct answer is B: Nasal congestion. After more than 5 days of use, nasal sympathomimetic medications like phenylephrine can lead to rebound nasal congestion. This occurs due to prolonged vasoconstriction of nasal blood vessels, causing worsening nasal congestion. Sedation (choice A) is not a common adverse effect of phenylephrine nasal drops. Productive cough (choice C) and constipation (choice D) are also not typical adverse effects associated with this medication.

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