Nursing Elites

1. The nurse is planning measures to decrease the incidence of chest pain for a client with angina pectoris. What intervention should the nurse do to effectively accomplish this goal?

• A. Provide a quiet and low-stimulus environment.
• B. Encourage the family to visit very frequently.
• C. Encourage the client to call friends and relatives each day.
• D. Recommend that the client watch TV as a constant diversion.

Correct answer: A

Rationale: The correct answer is A: Provide a quiet and low-stimulus environment. A calm and quiet environment can help reduce stress, which is beneficial in preventing the occurrence of chest pain in clients with angina. Choice B is incorrect because excessive or frequent visitations may lead to increased stress and agitation for the client. Choice C is incorrect as it may not always contribute to a calm environment and could potentially increase the client's stress levels. Choice D is inappropriate as watching TV constantly may not promote a quiet and low-stimulus environment, which is essential in managing angina pectoris.

2. 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.

3. 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.

4. When preparing to administer medication to a client, what action should the nurse take first?

• A. Verify the client's identity.
• B. Check the medication expiration date.
• C. Review the client's medical history.
• D. Obtain the client's vital signs.

Correct answer: A

Rationale: Verifying the client's identity is the initial and most critical step in medication administration. It is crucial to confirm that the right medication is being given to the correct patient. Checking the client's identity helps prevent medication errors and ensures patient safety. Checking the medication expiration date (choice B) is important but should come after verifying the client's identity. Reviewing the client's medical history (choice C) is valuable but not the first step in medication administration. Obtaining the client's vital signs (choice D) is essential in some situations but is usually not the first action needed before administering medication.

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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