Nursing Elites

1. When a client reports urticaria and dyspnea after receiving amoxicillin/clavulanic acid, which medication should be administered first?

• A. Administer epinephrine
• B. Administer albuterol
• C. Administer diphenhydramine
• D. Administer prednisone

Correct answer: A

Rationale: In the scenario described, the client is experiencing symptoms of a severe allergic reaction. The priority intervention is to administer epinephrine. Epinephrine acts quickly to reverse the effects of the allergic reaction and can be life-saving in cases of anaphylaxis. Albuterol is used for bronchodilation and may help with respiratory symptoms but is not the first-line treatment for anaphylaxis. Diphenhydramine and prednisone are used for allergic reactions but are not as rapid-acting as epinephrine and should be considered after administering epinephrine in this situation.

2. A client in the emergency department has Benzodiazepine toxicity due to an overdose. Which of the following actions is the nurse's priority?

• A. Administer flumazenil.
• B. Identify the client's level of orientation.
• C. Infuse IV fluids.
• D. Prepare the client for gastric lavage.

Correct answer: B

Rationale: In a situation where a client presents with Benzodiazepine toxicity, the priority action for the nurse is to assess the client. By identifying the client's level of orientation, the nurse can gather crucial information about the client's mental status, which is essential for determining the appropriate care and interventions needed. Administering flumazenil is used to reverse the effects of benzodiazepines but should be based on a comprehensive assessment. Infusing IV fluids and preparing for gastric lavage may be necessary interventions but should follow a thorough assessment of the client's condition to ensure proper prioritization of care.

3. A client has a new prescription for nitroglycerin transdermal patches. Which of the following instructions should the nurse include?

• A. Apply the patch to a different location each day.
• B. Remove the patch every night before bedtime.
• C. Massage the patch area gently after application.
• D. Shave the area before applying the patch.

Correct answer: B

Rationale: The correct instruction for a client using nitroglycerin transdermal patches is to remove the patch every night before bedtime. This practice helps prevent tolerance to the medication's effects. Continuous exposure to nitroglycerin can result in the body becoming less responsive to its therapeutic effects over time, reducing its efficacy in managing the prescribed condition. Choices A, C, and D are incorrect. Applying the patch to a different location each day does not address the issue of tolerance. Massaging the patch area gently after application is not recommended as it may alter drug absorption. Shaving the area before applying the patch is unnecessary and may increase the risk of skin irritation.

4. A healthcare provider is preparing to administer metoprolol to a client. Which of the following findings should the provider identify as a contraindication to receiving this medication?

• A. Bradycardia
• B. Hypertension
• C. Fever
• D. Rash

Correct answer: A

Rationale: Metoprolol, a beta-blocker, is contraindicated in clients with bradycardia as it can further lower the heart rate, potentially leading to more serious complications. Bradycardia is defined as a heart rate below 60 beats per minute, and administering metoprolol in such cases can exacerbate this condition, causing adverse effects on cardiac output. Hypertension, fever, and rash are not contraindications for metoprolol administration.

5. A client is receiving Enoxaparin for the prevention of deep vein thrombosis. Which of the following actions should the nurse take?

• A. Massage the injection site after administration.
• B. Administer the medication intramuscularly.
• C. Administer the medication into the subcutaneous tissue.
• D. Administer the medication into the deltoid muscle.

Correct answer: C

Rationale: Enoxaparin, a medication used for preventing deep vein thrombosis, should be administered into the subcutaneous tissue, typically in the abdomen. Administering the medication intramuscularly (Choice B) or into the deltoid muscle (Choice D) is incorrect because Enoxaparin is specifically formulated for subcutaneous administration. Massaging the injection site after administration (Choice A) is contraindicated as it may lead to tissue damage and affect the absorption of the medication. Therefore, the correct action is to administer the medication into the subcutaneous tissue as directed.

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