Nursing Elites

1. A nurse is teaching a client who has a new prescription for nitroglycerin sublingual tablets. Which of the following statements should the nurse include?

• A. "You can take this medication with a full glass of water."
• B. "You should store this medication in the refrigerator."
• C. "Take one tablet every 5 minutes until the pain is relieved, up to three doses."
• D. "You should avoid eating foods high in sodium while taking this medication."

Correct answer: C

Rationale: The correct statement the nurse should include is to take one nitroglycerin sublingual tablet every 5 minutes until the pain is relieved, up to three doses. This dosing regimen is important to manage angina attacks effectively. Option A is incorrect because nitroglycerin sublingual tablets should not be taken with water. Option B is incorrect as nitroglycerin tablets should be stored in their original container at room temperature. Option D is incorrect because there is no specific instruction to avoid foods high in sodium while taking nitroglycerin sublingual tablets.

2. A nurse is planning assignments for a licensed practical nurse (LPN) during a staffing shortage. Which client should be delegated to the LPN?

• A. A client with an Hgb of 6.3 g/dl and a prescription for packed RBCs.
• B. A client who sustained a concussion and has unequal pupils.
• C. A client who is postoperative following a bowel resection with an NG tube set to continuous suction.
• D. A client who fractured his femur yesterday and is experiencing shortness of breath.

Correct answer: C

Rationale: The correct answer is C because the client postoperative following a bowel resection with an NG tube set to continuous suction requires routine postoperative care, which an LPN can manage. Choice A involves administering blood products, which typically requires assessment and monitoring by a registered nurse. Choice B indicates a potentially serious neurological condition that requires assessment by a higher-level provider. Choice D suggests a client experiencing respiratory distress, which requires immediate assessment and intervention by a registered nurse or physician.

3. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets. After securing the client's airway and initiating an IV, which of the following actions should the nurse take next?

• A. Monitor the client's IV site for thrombophlebitis
• B. Administer flumazenil to the client
• C. Evaluate the client for further suicidal behavior
• D. Initiate seizure precautions for the client

Correct answer: B

Rationale: In cases of benzodiazepine overdose, such as diazepam ingestion, flumazenil is the antidote. Therefore, the priority action for the nurse is to administer flumazenil to the client. Monitoring the IV site for thrombophlebitis (Choice A) is important but not the immediate priority. Evaluating the client for further suicidal behavior (Choice C) is important but not the next immediate action. Initiating seizure precautions (Choice D) is not the priority as the client's airway has already been secured.

4. What is the primary action when a healthcare provider discovers a patient has fallen?

• A. Assess the patient for injuries
• B. Call for help immediately
• C. Document the fall
• D. Notify the healthcare provider

Correct answer: A

Rationale: When a healthcare provider discovers a patient has fallen, the primary action should be to assess the patient for injuries. This is crucial to determine the extent of harm and if immediate treatment is necessary. Calling for help is important, but assessing the patient's condition takes precedence to ensure the patient's safety and well-being. While documenting the fall and notifying the healthcare provider are essential steps, they come after assessing the patient's injuries.

5. A nurse is reviewing the medical record of a client who has thrombocytopenia. Which of the following actions should the nurse include in the care plan?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving raw vegetables.

Correct answer: C

Rationale: The correct action the nurse should include in the care plan for a client with thrombocytopenia is to provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to increased risk of bleeding. Stool softeners help prevent straining during bowel movements, which can reduce the risk of bleeding in individuals with thrombocytopenia. Encouraging the client to floss daily (Choice A) is unrelated to managing thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is more related to infection control rather than managing thrombocytopenia. Avoiding serving raw vegetables (Choice D) is more about reducing the risk of infection rather than managing thrombocytopenia.

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