Nursing Elites

1. Following the diagnosis of angina pectoris, a client reports being unable to walk up two flights of stairs without pain. Which of the following measures would most likely help the client prevent this problem?

• A. Climb the stairs early in the day.
• B. Rest for at least an hour before climbing the stairs.
• C. Take a nitroglycerin tablet before climbing the stairs.
• D. Lie down after climbing the stairs.

Correct answer: C

Rationale: The correct answer is to take a nitroglycerin tablet before climbing the stairs. Nitroglycerin helps prevent angina by dilating the coronary arteries, which increases blood flow to the heart. This medication can help reduce the chest pain and discomfort experienced during physical exertion. Climing the stairs early in the day (Choice A) does not address the underlying issue of inadequate blood flow to the heart. Resting for at least an hour before climbing the stairs (Choice B) may not be as effective in preventing angina as taking nitroglycerin. Lying down after climbing the stairs (Choice D) does not offer a preventive measure for angina; it is more focused on post-activity rest rather than prevention.

2. A client with partial thickness burns to the lower extremities is scheduled for whirlpool therapy to debride the burned area. Which intervention should the nurse implement before transporting the client to the physical therapy department?

• A. Obtain supplies to re-dress the burn area.
• B. Verify the client's signed consent form.
• C. Give a prescribed narcotic analgesic agent.
• D. Perform active range-of-motion exercises.

Correct answer: C

Rationale: Before transporting the client for whirlpool therapy to debride the burned area, the nurse should give a prescribed narcotic analgesic agent. This intervention is essential to manage pain effectively during the debridement process. Obtaining supplies to re-dress the burn area (Choice A) is important but not as immediate as providing pain relief. Verifying the client's signed consent form (Choice B) is necessary for procedures but does not address the client's immediate pain needs. Performing active range-of-motion exercises (Choice D) is not indicated before whirlpool therapy for debridement of burns and may cause further discomfort to the client.

3. The nurse is preparing to give a dose of oral clindamycin (Cleocin) to a patient being treated for a skin infection caused by Staphylococcus aureus. The patient has experienced nausea after several doses. What should the nurse do next?

• A. Administer the next dose when the patient has an empty stomach.
• B. Hold the next dose and contact the patient’s provider.
• C. Instruct the patient to take the next dose with a full glass of water.
• D. Request an order for an antacid to give along with the next dose.

Correct answer: C

Rationale: The correct action for the nurse to take next is to instruct the patient to take the next dose of clindamycin with a full glass of water. This is important to minimize gastrointestinal (GI) irritation such as nausea, vomiting, and stomatitis that the patient has been experiencing. Administering the medication on an empty stomach would likely worsen the GI upset. Holding the next dose and contacting the provider is not necessary at this point unless symptoms persist or worsen. Additionally, requesting an antacid is not indicated as the primary intervention for managing the nausea related to clindamycin.

4. The patient is being educated on taking hydrochlorothiazide. Which statement by the patient indicates a need for further teaching?

• A. I may need additional sodium and calcium while taking this medication.
• B. I should consume plenty of fruits and vegetables while taking this drug.
• C. I should be cautious when getting up from a bed or chair while on this medication.
• D. I will take the medication in the morning to reduce certain side effects.

Correct answer: A

Rationale: The correct answer is A because patients do not require extra sodium or calcium while taking hydrochlorothiazide, a thiazide diuretic. This medication actually promotes the excretion of sodium and water. Choices B, C, and D are correct statements regarding the use of hydrochlorothiazide. Patients are encouraged to have a diet rich in fruits and vegetables, be careful with position changes due to potential orthostatic hypotension, and take the medication in the morning to reduce the need for frequent urination during nighttime.

5. A nurse reviews the urinalysis of a client and notes the presence of glucose. Which action should the nurse take?

• A. Document findings and continue to monitor the client.
• B. Contact the provider and recommend a 24-hour urine test.
• C. Review the client’s recent dietary selections.
• D. Perform a capillary artery glucose assessment.

Correct answer: D

Rationale: Glucose normally is not found in the urine. The normal renal threshold for glucose is about 220 mg/dL, which means that a person whose blood glucose is less than 220 mg/dL will not have glucose in the urine. A positive finding for glucose on urinalysis indicates high blood sugar. The most appropriate action would be to perform a capillary artery glucose assessment. The client needs further evaluation for this abnormal result; therefore, documenting and continuing to monitor is not appropriate. Requesting a 24-hour urine test or reviewing the client’s dietary selections will not assist the nurse to make a clinical decision related to this abnormality.

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