Nursing Elites

1. The client has angina pectoris and is prescribed nitroglycerin patches. What instruction should the nurse provide to the client?

• A. Apply the patch to the chest and leave it in place for 24 hours
• B. Apply the patch to a different site each time to prevent skin irritation
• C. Remove the patch before going to bed to prevent tolerance
• D. Cut the patch in half if experiencing headaches

Correct answer: B

Rationale: The correct instruction for the nurse to provide to the client is to apply the nitroglycerin patch to a different site each time to prevent skin irritation. Rotating the application site is crucial to prevent skin irritation and ensure consistent absorption of the medication. Applying the patch to the same site can lead to skin irritation and decreased effectiveness. Removing the patch before going to bed is not necessary, as the patch can typically be worn for a specific duration. Cutting the patch in half if experiencing headaches is not recommended and can alter the dose of the medication.

2. A client with a history of coronary artery disease (CAD) is prescribed atorvastatin (Lipitor). The nurse should teach the client about which common side effect of this medication?

• A. Dry mouth
• B. Muscle pain
• C. Drowsiness
• D. Diarrhea

Correct answer: B

Rationale: Muscle pain is a common side effect of statins like atorvastatin. It is important for the nurse to educate the client about this potential side effect, as it can indicate a serious condition called rhabdomyolysis, which requires immediate medical attention. Dry mouth, drowsiness, and diarrhea are not typically associated with atorvastatin use.

3. A client being seen in the emergency department for complaints of chest pain confides in the nurse about regular use of cocaine as a recreational drug. The nurse takes which important action in delivering holistic nursing care to this client?

• A. Reports the client to the police for illegal drug use
• B. Explains to the client the damage that cocaine does to the heart
• C. Tells the client it is imperative to stop before myocardial infarction occurs
• D. Teaches about the effects of cocaine on the heart and offers a referral for further help

Correct answer: D

Rationale: In this scenario, the nurse should prioritize educating the client about the effects of cocaine on the heart and provide a referral for further help. This approach is crucial in addressing the root cause of the client's health issues and supporting them in making informed decisions about their health. Reporting the client to the police is not appropriate in this situation as the focus should be on the client's health and well-being. Simply explaining the damage without offering solutions may not effectively address the client's needs or promote holistic care. Telling the client to stop without providing support or education may not be as effective as teaching about the effects of cocaine and offering help for cessation. Therefore, educating about the effects and providing a referral for further assistance is the best course of action for holistic nursing care.

4. The healthcare provider notes this rhythm on the client's cardiac monitor. The healthcare provider next reports that the client is experiencing which heart rhythm?

• A. Normal sinus
• B. Atrial fibrillation
• C. Sinus bradycardia
• D. Ventricular fibrillation

Correct answer: B

Rationale: The correct answer is B, Atrial fibrillation. Atrial fibrillation is characterized by an irregular and often rapid heart rate, which can lead to poor blood flow due to ineffective contractions of the atria. Sinus bradycardia (Choice C) is a regular but slow heart rhythm originating from the sinus node. Normal sinus rhythm (Choice A) refers to a regular heartbeat originating from the sinus node. Ventricular fibrillation (Choice D) is a life-threatening arrhythmia characterized by rapid, uncoordinated contractions of the ventricles.

5. A client with a history of angina pectoris reports chest pain while ambulating in the corridor. What should the nurse do first?

• A. Check the client's vital signs.
• B. Assist the client to sit or lie down.
• C. Administer sublingual nitroglycerin.
• D. Apply nasal oxygen at a rate of 2 L/min.

Correct answer: B

Rationale: When a client with a history of angina pectoris experiences chest pain while ambulating, the priority action for the nurse is to assist the client to sit or lie down. This helps reduce the demand on the heart by decreasing physical exertion. Checking vital signs, administering medication, or applying oxygen can follow once the client is in a more comfortable position. Checking vital signs (Choice A) may be important but addressing the immediate discomfort by positioning the client comfortably takes precedence. Administering sublingual nitroglycerin (Choice C) is appropriate but should come after ensuring the client's comfort. Applying nasal oxygen (Choice D) can be beneficial, but it should not be the first action; assisting the client to sit or lie down is the initial priority.

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