Nursing Elites

1. A nurse is caring for a client who has a history of angina. The client reports chest pain. Which of the following actions should the nurse take?

• A. Administer sublingual nitroglycerin every 5 minutes
• B. Administer aspirin 325 mg
• C. Encourage the client to use deep breathing exercises
• D. Apply oxygen at 2 L/min via nasal cannula

Correct answer: A

Rationale: The correct action for the nurse to take when a client with a history of angina reports chest pain is to administer sublingual nitroglycerin every 5 minutes. Nitroglycerin helps dilate blood vessels, improving blood flow to the heart and relieving chest pain associated with angina. Aspirin is often given during a suspected heart attack, not for immediate relief of angina. Deep breathing exercises may be beneficial for anxiety or respiratory conditions but are not the first-line intervention for angina. Oxygen therapy is not the initial treatment for angina unless the client is hypoxic.

2. A nurse is providing discharge teaching to a client who has a new prescription for lithium. Which of the following instructions should the nurse include?

• A. Take this medication on an empty stomach.
• B. Avoid eating foods that contain tyramine.
• C. Drink at least 2 liters of water each day.
• D. Take this medication in the evening before bedtime.

Correct answer: C

Rationale: The correct instruction for a client prescribed lithium is to drink at least 2 liters of water each day. This is important to prevent dehydration and reduce the risk of lithium toxicity. Option A is incorrect because lithium is usually taken with food to minimize gastrointestinal side effects. Option B is unrelated to lithium and is more applicable to clients taking MAOIs. Option D is incorrect as lithium is typically taken in divided doses throughout the day to maintain therapeutic levels.

3. A healthcare provider is assessing a client who has heart failure and is taking digoxin. Which of the following findings should the healthcare provider identify as an indication of digoxin toxicity?

• A. Bradycardia.
• B. Yellow-tinged vision.
• C. Constipation.
• D. Hypertension.

Correct answer: B

Rationale: Yellow-tinged vision is a classic sign of digoxin toxicity due to its effect on the eyes. It can cause a yellow or green visual halo around objects. Bradycardia, constipation, and hypertension are not typical signs of digoxin toxicity. Bradycardia may be a sign of digoxin's therapeutic effect in heart failure, while constipation and hypertension are not commonly associated with digoxin toxicity.

4. A nurse is planning care for a client who has diabetes insipidus and is receiving desmopressin. Which of the following should the nurse monitor?

• A. Fasting blood glucose
• B. Carbohydrate intake
• C. Hematocrit
• D. Weight

Correct answer: D

Rationale: The correct answer is D: Weight. Weight monitoring is essential to assess the effectiveness of desmopressin therapy, as fluid retention is a common side effect. Monitoring fasting blood glucose (choice A) is not directly related to desmopressin therapy for diabetes insipidus. Monitoring carbohydrate intake (choice B) may be important in diabetes management but is not specific to desmopressin therapy. Hematocrit (choice C) monitoring is not a primary concern when managing diabetes insipidus with desmopressin.

5. A nurse is preparing to administer an immunization to a 6-month-old infant. Which of the following actions should the nurse take to reduce pain at the injection site?

• A. Administer the immunization in the deltoid muscle
• B. Apply a cold compress to the injection site
• C. Apply pressure to the injection site for 5 minutes
• D. Administer a local anesthetic at the injection site

Correct answer: D

Rationale: Administering a local anesthetic at the injection site can help reduce pain during immunizations in infants. Options A, B, and C are incorrect. Administering the immunization in the deltoid muscle may not provide pain relief. Applying a cold compress or pressure to the injection site is not as effective as using a local anesthetic to reduce pain.

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