Nursing Elites

1. When monitoring a client for acute toxicity associated with bethanechol chloride (Urecholine), what sign should the nurse check for to indicate toxicity?

• A. Dry skin
• B. Dry mouth
• C. Bradycardia
• D. Signs of dehydration

Correct answer: C

Rationale: The correct answer is C: Bradycardia. Toxicity from bethanechol chloride (Urecholine) can lead to excessive muscarinic stimulation, resulting in manifestations like salivation, sweating, involuntary urination and defecation, bradycardia, and severe hypotension. When facing toxicity, treatment involves supportive measures and administering atropine sulfate subcutaneously or intravenously.

2. A clinic nurse prepares to administer an MMR (measles, mumps, rubella) vaccine to a child. How is this vaccine best administered?

• A. Intramuscularly in the deltoid muscle
• B. Subcutaneously in the gluteal muscle
• C. Subcutaneously in the outer aspect of the upper arm
• D. Intramuscularly in the anterolateral aspect of the thigh

Correct answer: C

Rationale: The MMR vaccine is best administered subcutaneously in the outer aspect of the upper arm. This route allows for proper absorption and efficacy of the vaccine while minimizing the risk of injury or discomfort to the child.

3. Mafenide acetate (Sulfamylon) is prescribed for a client with a burn injury. When applying the medication, the client complains of local discomfort and burning. Which of the following is the most appropriate nursing action?

• A. Notifying the registered nurse
• B. Discontinuing the medication
• C. Informing the client that this is normal
• D. Applying a thinner film than prescribed to the burn site

Correct answer: C

Rationale: The correct action is to inform the client that local discomfort and burning are normal reactions to Mafenide acetate. This medication is used to treat burns by reducing bacteria in avascular tissues. Discontinuing the medication or applying a thinner film than prescribed is not necessary or recommended in this situation.

4. A client is being taught about the use of nitroglycerin (Nitrostat) for angina. Which statement by the client indicates a need for further teaching?

• A. I will sit or lie down when I take the medication.
• B. I can take up to three tablets, 5 minutes apart, if needed.
• C. I will call 911 if my chest pain is not relieved after taking three tablets.
• D. I will keep the medication in its original dark container.

Correct answer: B

Rationale: The correct administration of nitroglycerin for angina is to take up to three tablets, 5 minutes apart. If the chest pain persists after the third tablet, emergency medical services should be called. Taking more than three tablets or reducing the time interval between doses may lead to hypotension and indicates a need for further teaching.

5. A client is being educated about the use of sertraline (Zoloft) for depression. Which statement by the client indicates a need for further teaching?

• A. I should take the medication with a high-protein meal.
• B. I may experience dizziness when getting up quickly.
• C. I might notice a decrease in my sex drive.
• D. I should report any thoughts of self-harm to my healthcare provider.

Correct answer: A

Rationale: The statement 'I should take the medication with a high-protein meal' indicates a need for further teaching as sertraline (Zoloft) should not be taken with a high-protein meal due to potential interference with medication absorption. Choices B, C, and D are correct statements associated with the use of sertraline for depression. It is common to experience dizziness when quickly getting up, notice a decrease in sex drive, and important to report any thoughts of self-harm to the healthcare provider while on this medication.

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