Nursing Elites

1. A nurse is assessing a client who is taking hydrocodone. Which of the following findings should the nurse report to the provider?

• A. Constipation
• B. Sedation
• C. Dry mouth
• D. Respiratory depression

Correct answer: D

Rationale: The correct answer is D: Respiratory depression. Hydrocodone is an opioid medication that can cause respiratory depression, a serious side effect that should be reported immediately to the healthcare provider. Constipation, sedation, and dry mouth are common side effects of hydrocodone but are not as concerning as respiratory depression. Constipation can be managed with lifestyle modifications and medications, sedation may improve with time or dosage adjustments, and dry mouth is a common and usually benign side effect.

2. A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit with cardiac monitoring via telemetry. The nurse assisting in caring for the client expects to note which type of activity prescribed?

• A. Strict bed rest for 24 hours
• B. Bathroom privileges and self-care activities
• C. Unrestricted activities because the client is monitored
• D. Unsupervised hallway ambulation with distances less than 200 feet

Correct answer: B

Rationale: After being transferred from the CCU to the general medical unit with cardiac monitoring, the client with MI is typically prescribed bathroom privileges and self-care activities. This approach allows for gradual recovery and mobility while still being closely monitored, promoting the client's overall well-being and independence. Choice A, strict bed rest for 24 hours, is too restrictive and not recommended for MI patients as it can lead to complications like deep vein thrombosis. Choice C, unrestricted activities, is also not appropriate as MI patients usually require monitoring and gradual re-introduction to activities. Choice D, unsupervised hallway ambulation with distances less than 200 feet, may be too strenuous for a client who just got transferred from the CCU and needs a more gradual approach to activity.

3. 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.

4. A client with a history of coronary artery disease (CAD) is being discharged with a prescription for aspirin. Which instruction should the nurse reinforce with the client?

• A. Take the aspirin on an empty stomach for better absorption.
• B. Stop taking the aspirin if you experience any stomach discomfort.
• C. Take the aspirin with food to reduce the risk of stomach irritation.
• D. Take the aspirin only when you have chest pain.

Correct answer: C

Rationale: The correct instruction is to take the aspirin with food to reduce the risk of stomach irritation. This is crucial for clients with a history of coronary artery disease as it helps minimize gastrointestinal side effects like irritation and bleeding. Option A is incorrect because aspirin should not be taken on an empty stomach to prevent stomach upset. Option B is incorrect because discontinuing aspirin at the first sign of stomach discomfort can be harmful, and a healthcare provider should be consulted instead. Option D is incorrect because aspirin is often prescribed for prevention in cardiovascular conditions, not just for chest pain relief.

5. A nurse is assessing a client who has been taking phenytoin for epilepsy. Which of the following findings should the nurse report to the provider?

• A. Weight loss
• B. Gingival hyperplasia
• C. Increased thirst
• D. Frequent urination

Correct answer: B

Rationale: The correct answer is B: Gingival hyperplasia. Phenytoin is known to cause gingival hyperplasia, an overgrowth of gum tissue, which can lead to oral health issues and requires dental care. Choices A, C, and D are not directly associated with phenytoin use. Weight loss, increased thirst, and frequent urination are not typically reported findings related to phenytoin and should not be prioritized over gingival hyperplasia when assessing a client taking this medication.

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