Nursing Elites

1. The client with angina is being discharged to home. The nurse is instructing the client on dietary changes. What should be included in this teaching?

• A. Decrease salt and fat intake and limit alcohol intake.
• B. There are no dietary restrictions for a person diagnosed with angina.
• C. Limit smoking and increase protein and sugar intake.
• D. Increase fruits, vegetables, and foods high in cholesterol.

Correct answer: A

Rationale: The correct answer is to decrease salt and fat intake and limit alcohol intake. These dietary changes can help manage angina by reducing the workload on the heart and preventing further plaque buildup in the arteries. Choices B, C, and D are incorrect as dietary restrictions for angina typically involve reducing salt, fat, and alcohol intake, rather than increasing sugar or cholesterol intake.

2. A client with HIV is starting therapy with zidovudine. The nurse should monitor the client for which of the following adverse effects of this medication?

• A. Fatigue
• B. Blurred vision
• C. Ringing in the ears
• D. Constipation

Correct answer: A

Rationale: Fatigue is a common adverse effect of zidovudine due to its impact on bone marrow, leading to anemia. Zidovudine is known to cause bone marrow suppression, resulting in decreased production of red blood cells and subsequent fatigue.

3. 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.

4. A healthcare professional is preparing to administer IV Dantrolene to a client who has developed Malignant Hyperthermia during surgery. Which of the following actions should the healthcare professional take?

• A. Dilute the medication with sterile water and administer it rapidly.
• B. Store the medication in a refrigerator until use.
• C. Administer the medication through a large-bore IV catheter.
• D. Administer the medication via an infusion pump over 60 minutes.

Correct answer: C

Rationale: Dantrolene should be administered through a large-bore IV catheter because it is highly irritating to tissues and can cause vein irritation or thrombophlebitis if administered through a small vein. Using a large-bore IV catheter helps to minimize the risk of tissue damage and ensures proper and safe administration of the medication in emergency situations like Malignant Hyperthermia. Choices A, B, and D are incorrect because diluting the medication with sterile water and administering it rapidly can lead to tissue damage, storing the medication in a refrigerator is not necessary, and administering the medication via an infusion pump over 60 minutes is not appropriate in emergency situations like Malignant Hyperthermia where rapid administration is crucial.

5. A client in the emergency department has Benzodiazepine toxicity due to an overdose. Which of the following actions is the nurse's priority?

• A. Administer flumazenil.
• B. Identify the client's level of orientation.
• C. Infuse IV fluids.
• D. Prepare the client for gastric lavage.

Correct answer: B

Rationale: In a situation where a client presents with Benzodiazepine toxicity, the priority action for the nurse is to assess the client. By identifying the client's level of orientation, the nurse can gather crucial information about the client's mental status, which is essential for determining the appropriate care and interventions needed. Administering flumazenil is used to reverse the effects of benzodiazepines but should be based on a comprehensive assessment. Infusing IV fluids and preparing for gastric lavage may be necessary interventions but should follow a thorough assessment of the client's condition to ensure proper prioritization of care.

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