Nursing Elites

1. The client is receiving intravenous heparin for the treatment of a pulmonary embolism. Which medication should the nurse ensure is readily available?

• A. Protamine sulfate
• B. Vitamin K
• C. Calcium gluconate
• D. Magnesium sulfate

Correct answer: A

Rationale: Protamine sulfate is the antidote for heparin, used to reverse its anticoagulant effects. It should be readily available in case of bleeding complications, as it can rapidly neutralize the effects of heparin and prevent excessive bleeding. Vitamin K is used to reverse the effects of warfarin, not heparin (Choice B). Calcium gluconate is used to treat calcium deficiencies, not indicated for heparin therapy (Choice C). Magnesium sulfate is used for conditions like preeclampsia and eclampsia, not for reversing heparin effects (Choice D).

2. A client has a new prescription for sertraline. Which of the following instructions should the nurse include?

• A. Take the medication in the morning.
• B. Avoid consuming grapefruit juice.
• C. Take the medication with a full glass of water.
• D. Monitor for signs of weight gain.

Correct answer: B

Rationale: The correct instruction for the nurse to include is to 'Avoid consuming grapefruit juice.' Grapefruit juice can increase sertraline levels, leading to an elevated risk of side effects. Instructing the client to avoid grapefruit juice is crucial to prevent potential interactions that could impact the effectiveness and safety of the medication. The other options are not directly related to sertraline administration. Taking the medication in the morning may vary depending on individual preferences or the prescriber's directions. Taking the medication with a full glass of water is a general instruction for many medications and not specific to sertraline. Monitoring for signs of weight gain is important but not a direct instruction related to taking sertraline.

3. A client with a history of angina pectoris reports chest pain after climbing stairs. What should be the nurse's first action?

• A. Administer oxygen.
• B. Administer nitroglycerin.
• C. Sit the client down and rest.
• D. Check the client's blood pressure.

Correct answer: C

Rationale: The correct action for a client experiencing anginal pain, like chest pain after climbing stairs, is to sit the client down and have them rest. Resting reduces myocardial oxygen demand, which can help relieve anginal pain. Administering oxygen or nitroglycerin may be appropriate interventions after the client has been seated and rested. Checking the client's blood pressure is important but not the immediate priority when a client is experiencing anginal pain. Therefore, the first action should be to sit the client down and allow them to rest.

4. When teaching a client who has a new prescription for metformin, which of the following instructions should the nurse include?

• A. Take the medication with food.
• B. Monitor for signs of hyperglycemia.
• C. Increase your fluid intake.
• D. Expect a metallic taste in your mouth.

Correct answer: C

Rationale: The correct instruction for a client starting metformin is to increase fluid intake. This is crucial to prevent gastrointestinal discomfort, a common side effect of metformin. Adequate hydration helps reduce the risk of gastrointestinal upset and ensures the medication is well-tolerated. Option A is generally true for metformin but is not as essential as maintaining proper hydration. Option B is important but not directly related to starting metformin. Option D is incorrect as a metallic taste in the mouth is not typically associated with metformin.

5. A client with hypertension is prescribed enalapril (Vasotec). The nurse should monitor the client for which adverse effect?

• A. Hypotension
• B. Hypertension
• C. Tachycardia
• D. Hyperglycemia

Correct answer: A

Rationale: Enalapril, an ACE inhibitor, can lead to hypotension, particularly following the initial dose or dosage escalation. This effect is due to the medication's mechanism of action in dilating blood vessels, which can result in lowered blood pressure. Monitoring for hypotension is crucial to prevent complications such as dizziness, lightheadedness, or fainting in clients taking enalapril. Choices B, C, and D are incorrect because enalapril does not typically cause hypertension, tachycardia, or hyperglycemia as adverse effects.

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