Nursing Elites

1. Atenolol hydrochloride (Tenormin) is prescribed for a hospitalized client. The nurse should perform which of the following as a priority action before administering the medication?

• A. Listen to the client's lung sounds.
• B. Check the client's blood pressure.
• C. Check the recent electrolyte levels.
• D. Assess the client for muscle weakness.

Correct answer: B

Rationale: Atenolol hydrochloride is a beta-blocker used to treat hypertension. Checking the client's blood pressure is crucial before administration.

2. A client is receiving morphine sulfate for pain management. Which assessment finding requires immediate action?

• A. Constipation
• B. Drowsiness
• C. Respiratory rate of 10 breaths per minute
• D. Nausea

Correct answer: C

Rationale: A respiratory rate of 10 breaths per minute indicates respiratory depression, a serious side effect of morphine sulfate that can lead to respiratory compromise and requires immediate intervention. Constipation, drowsiness, and nausea are common side effects of morphine but are not immediately life-threatening compared to respiratory depression. Monitoring and addressing a low respiratory rate are crucial in preventing further respiratory distress or failure.

3. A client with a prescription to take theophylline (Theo-24) daily has been given medication instructions by the nurse. The nurse determines that the client needs further information about the medication if the client states that he or she will:

• A. Drink at least 2 L of fluid per day.
• B. Take the daily dose at bedtime.
• C. Avoid changing brands of the medication without health care provider (HCP) approval.
• D. Avoid over-the-counter (OTC) cough and cold medications unless approved by the HCP.

Correct answer: B

Rationale: The correct answer is B. Taking theophylline at bedtime is inappropriate because it can cause insomnia. The medication should be taken early in the morning to avoid disrupting sleep patterns. It is important to follow the healthcare provider's instructions regarding the timing of the medication to achieve optimal therapeutic effects.

4. The client with breast cancer is receiving cyclophosphamide (Neosar). The nurse is reinforcing medication instructions and advises the client to:

• A. Take the medication with food.
• B. Increase fluid intake to 2000 to 3000 mL daily.
• C. Decrease sodium intake while taking the medication.
• D. Increase potassium intake while taking the medication.

Correct answer: B

Rationale: The correct answer is to increase fluid intake to 2000 to 3000 mL daily. Cyclophosphamide can cause hemorrhagic cystitis as a toxic effect. By increasing fluid intake, the client can help prevent this complication by promoting frequent urination, which reduces the concentration of the drug and its metabolites in the bladder. This dilution effect can help reduce the risk of bladder toxicity.

5. While assisting in caring for a pregnant client receiving intravenous magnesium sulfate for preeclampsia management, a nurse notes the client's absent deep tendon reflexes. What determination should the nurse make based on this data?

• A. The magnesium sulfate is effective.
• B. The infusion rate needs to be increased.
• C. The client is experiencing cerebral edema.
• D. The client is experiencing magnesium toxicity.

Correct answer: D

Rationale: When a pregnant client receiving intravenous magnesium sulfate for preeclampsia management exhibits absent deep tendon reflexes, this indicates magnesium toxicity. Magnesium toxicity can occur as a complication of magnesium sulfate therapy, leading to suppressed reflexes. It is crucial for the nurse to recognize this sign promptly and report it to prevent further complications or harm to the client.

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