Nursing Elites

1. The nurse provides medication instructions to an older hypertensive client who is taking 20 mg of lisinopril (Prinivil, Zestril) orally daily. The nurse evaluates the need for further teaching when the client states which of the following?

• A. I can skip a dose once a week.
• B. I need to change my position slowly.
• C. I take the pill after breakfast each day.
• D. If I get a bad headache, I should call my doctor immediately.

Correct answer: A

Rationale: Lisinopril should be taken daily as prescribed and not skipped. Skipping doses can lead to ineffective treatment.

2. A client with angina pectoris is experiencing chest pain that radiates down the left arm. The nurse administers a sublingual nitroglycerin tablet to the client. The client's pain is unrelieved, and the nurse determines that the client needs another nitroglycerin tablet. Which of the following vital signs is most important for the nurse to check before administering the medication?

• A. Temperature
• B. Respirations
• C. Blood pressure
• D. Radial pulse rate

Correct answer: C

Rationale: The correct answer is checking the client's blood pressure (C) before administering another nitroglycerin tablet. Nitroglycerin can cause hypotension, and monitoring blood pressure is crucial to prevent a sudden drop in blood pressure, especially when giving another dose of nitroglycerin.

3. A postoperative client has received a dose of naloxone hydrochloride for respiratory depression shortly after transfer to the nursing unit from the postanesthesia care unit. After administration of the medication, the nurse checks the client for:

• A. Pupillary changes
• B. Scattered lung wheezes
• C. Sudden increase in pain
• D. Sudden episodes of diarrhea

Correct answer: C

Rationale: Naloxone hydrochloride is an antidote to opioids and may be administered to postoperative clients to address respiratory depression. This medication can also reverse the effects of analgesics, potentially leading to a sudden increase in pain. Therefore, the nurse must assess the client for any unexpected rise in pain levels after naloxone administration. Choices A, B, and D are incorrect because pupillary changes, scattered lung wheezes, and sudden episodes of diarrhea are not typically associated with naloxone administration for respiratory depression.

4. A client is being taught about the use of nitroglycerin (Nitrostat) for angina. Which statement by the client indicates a need for further teaching?

• A. I will sit or lie down when I take the medication.
• B. I can take up to three tablets, 5 minutes apart, if needed.
• C. I will call 911 if my chest pain is not relieved after taking three tablets.
• D. I will keep the medication in its original dark container.

Correct answer: B

Rationale: The correct administration of nitroglycerin for angina is to take up to three tablets, 5 minutes apart. If the chest pain persists after the third tablet, emergency medical services should be called. Taking more than three tablets or reducing the time interval between doses may lead to hypotension and indicates a need for further teaching.

5. The clinic nurse is reviewing a teaching plan for a client receiving antineoplastic medication. When implementing the plan, the nurse should advise the client:

• A. To take aspirin (acetylsalicylic acid) as needed for a headache
• B. To avoid drinking beverages containing alcohol
• C. To consult with healthcare providers (HCPs) before receiving immunizations
• D. That it is necessary to consult HCPs before receiving a flu vaccine at the local health fair

Correct answer: C

Rationale: The correct advice for a client receiving antineoplastic medication is to consult with healthcare providers (HCPs) before receiving immunizations. Antineoplastic medications can lower the body's resistance, making it crucial to seek guidance from healthcare providers to prevent potential complications that may arise due to the medication's impact on the immune system. Choices A, B, and D are incorrect because taking aspirin for a headache, avoiding alcohol, and consulting only before a flu vaccine at a local health fair do not directly address the specific risk related to antineoplastic medications and immunizations.

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