Nursing Elites

1. A client is diagnosed with an acute myocardial infarction and is receiving tissue plasminogen activator, alteplase (Activase, tPA). Which action is a priority nursing intervention?

• A. Monitor for renal failure.
• B. Monitor psychosocial status.
• C. Monitor for signs of bleeding.
• D. Have heparin sodium available.

Correct answer: C

Rationale: The priority nursing intervention for a client receiving tissue plasminogen activator (alteplase) for an acute myocardial infarction is to monitor for signs of bleeding. Alteplase is a thrombolytic medication that can lead to hemorrhage as a complication. Therefore, closely monitoring the client for any signs of bleeding is essential to promptly address and manage this potential adverse effect.

2. Atenolol hydrochloride (Tenormin) is prescribed for a hospitalized client. The nurse should perform which of the following as a priority action before administering the medication?

• A. Listen to the client's lung sounds.
• B. Check the client's blood pressure.
• C. Check the recent electrolyte levels.
• D. Assess the client for muscle weakness.

Correct answer: B

Rationale: Atenolol hydrochloride is a beta-blocker used to treat hypertension. Checking the client's blood pressure is crucial before administration.

3. The client with ovarian cancer is being treated with vincristine (Oncovin). The nurse monitors the client, knowing that which of the following indicates a side effect specific to this medication?

• A. Diarrhea
• B. Hair loss
• C. Chest pain
• D. Numbness and tingling in the fingers and toes

Correct answer: D

Rationale: The correct answer is D: Numbness and tingling in the fingers and toes. Vincristine is known to cause peripheral neuropathy as a side effect, resulting in numbness and tingling in the fingers and toes. Diarrhea, hair loss, and chest pain are not typically associated with vincristine use.

4. Insulin glargine (Lantus) is prescribed for a client with diabetes mellitus. The nurse tells the client that it is best to take the insulin:

• A. 1 hour after each meal
• B. Once daily, at the same time each day
• C. 15 minutes before breakfast, lunch, and dinner
• D. Before each meal, based on the blood glucose level

Correct answer: B

Rationale: Insulin glargine (Lantus) is a long-acting insulin with a duration of action of approximately 24 hours, making it suitable for once-daily dosing at the same time each day. This regimen helps maintain consistent blood glucose levels and simplifies the client's treatment routine. Taking insulin glargine once daily provides basal insulin coverage throughout the day, reducing the risk of hypoglycemia compared to short-acting insulins that are taken before each meal.

5. A nurse is providing instructions to an adolescent who has a history of seizures and is taking an anticonvulsant medication. Which of the following statements indicates that the client understands the instructions?

• A. I will never be able to drive a car.
• B. My anticonvulsant medication will clear up my skin.
• C. I can't drink alcohol while I am taking my medication.
• D. If I forget my morning medication, I can take two pills at bedtime.

Correct answer: C

Rationale: The correct answer is C: 'I can't drink alcohol while I am taking my medication.' Alcohol can lower the seizure threshold and should be avoided by individuals taking anticonvulsants. Choice A is incorrect because it is an extreme statement and not necessary for someone taking anticonvulsants. Choice B is incorrect as anticonvulsant medications are not used to clear skin conditions. Choice D is incorrect because doubling up medication doses can be harmful and should not be done without healthcare provider approval.

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