Nursing Elites

1. Reteplase (Retavase) has been ordered for a client diagnosed with an MI. The nurse understands that this drug needs to be administered within which time frame following the onset of symptoms?

• A. 45 minutes to 18 hours
• B. 30 minutes to 12 hours
• C. 90 minutes to 36 hours
• D. 60 minutes to 24 hours

Correct answer: B

Rationale: Reteplase (Retavase) is a thrombolytic medication used in the treatment of myocardial infarction (MI). It is crucial to administer this drug within 30 minutes to 12 hours following the onset of symptoms to achieve optimal therapeutic effects and improve patient outcomes. Administering Reteplase within this time frame helps in restoring blood flow to the affected areas of the heart by dissolving blood clots, reducing myocardial damage, and potentially preventing further complications associated with MI.

2. A healthcare provider is planning to administer Ciprofloxacin IV to a client who has cystitis. Which of the following actions should the healthcare provider take?

• A. Administer a concentrated solution.
• B. Infuse the medication over 60 min.
• C. Infuse the solution through the primary IV fluid tubing.
• D. Choose a small peripheral vein for administration.

Correct answer: B

Rationale: Ciprofloxacin should be infused over 60 minutes to minimize vein irritation and reduce the risk of adverse effects. Administering a concentrated solution can lead to vein irritation and potential complications. Infusing the solution through the primary IV fluid tubing can cause incompatibility issues. Choosing a small peripheral vein may not be suitable for administering Ciprofloxacin, which should be infused through a larger vein to prevent vein irritation and ensure a proper dilution of the medication.

3. A client has an infection and a prescription for gentamicin intermittent IV bolus every 8 hr. A peak and trough is required with the next dose. Which of the following actions should be taken to obtain an accurate gentamicin serum level?

• A. Draw a trough level immediately prior to administering the medication and a peak level 30 min after the dose.
• B. Draw a peak level 90 min prior to administering the medication and a trough level 90 min after the dose.
• C. Draw a trough level immediately prior to administering the medication and a peak level 30 min after the dose.
• D. Draw a peak level at 0900 and a trough level at 2100.

Correct answer: C

Rationale: To obtain an accurate gentamicin serum level, the trough should be drawn immediately before administering the medication, and the peak level should be drawn 30 minutes after the dose. This timing allows for the assessment of the lowest and highest drug concentrations in the bloodstream, ensuring therapeutic levels are achieved while minimizing the risk of toxicity. Choice A is correct as it follows this timing protocol. Choices B and D have incorrect timing for peak and trough levels, which would not provide an accurate representation of the drug's concentration in the bloodstream.

4. When a client is taking Somatropin to stimulate growth, what should the healthcare provider monitor the client's urine for?

• A. Bilirubin
• B. Protein
• C. Potassium
• D. Calcium

Correct answer: D

Rationale: When a client is taking Somatropin to stimulate growth, monitoring urine for calcium is essential. Somatropin can lead to increased calcium levels in the urine, potentially increasing the risk of renal calculi formation. Therefore, assessing for calcium in the urine helps in early detection and prevention of this complication. Monitoring for bilirubin, protein, or potassium in the urine is not directly related to the effects of Somatropin and would not provide relevant information in this context.

5. A client with streptococcal pneumonia is receiving penicillin G by intermittent IV bolus. 10 minutes into the infusion of the third dose, the client reports itching at the IV site, dizziness, and shortness of breath. What should the nurse do first?

• A. Stop the infusion.
• B. Call the provider.
• C. Elevate the head of the bed.
• D. Auscultate breath sounds.

Correct answer: A

Rationale: In this scenario, the client is exhibiting signs of anaphylaxis, a severe allergic reaction. The priority action for the nurse is to stop the infusion immediately to prevent further administration of the allergen and worsening symptoms. Once the infusion is stopped, the nurse can then proceed with additional interventions, such as calling the provider, assessing the client's respiratory status, and providing appropriate care as needed.

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