Nursing Elites

1. A client just received their first dose of lisinopril. Which of the following is an appropriate nursing intervention?

• A. Place the client on cardiac monitoring
• B. Monitor the client’s oxygen saturation
• C. Provide standby assistance when the client gets out of bed
• D. Encourage foods high in potassium

Correct answer: C

Rationale: The correct answer is to provide standby assistance when the client gets out of bed. Lisinopril can cause hypotension, especially after the first dose, which can lead to dizziness and falls. Standby assistance helps prevent potential injury. Placing the client on cardiac monitoring (choice A) or monitoring oxygen saturation (choice B) are not typically necessary after the first dose of lisinopril unless specific symptoms are present. Encouraging foods high in potassium (choice D) is not directly related to the immediate concern of postural hypotension associated with lisinopril.

2. A nurse is caring for a client who has a prescription for enalapril. The nurse should monitor the client for which of the following adverse effects of this medication?

• A. Bradycardia
• B. Hyperkalemia
• C. Hyperglycemia
• D. Tinnitus

Correct answer: B

Rationale: The correct answer is B: Hyperkalemia. Enalapril, an ACE inhibitor, can lead to hyperkalemia by reducing aldosterone levels, which results in potassium retention. Bradycardia (Choice A) is not a common adverse effect of enalapril. Hyperglycemia (Choice C) and tinnitus (Choice D) are also not typically associated with enalapril use.

3. A nurse is assessing a newborn 1 hour after birth. The newborn has acrocyanosis and a heart rate of 130 beats per minute. Which of the following actions should the nurse take?

• A. Place the newborn under a radiant warmer
• B. Apply oxygen
• C. Swaddle the newborn
• D. Reassess the newborn in 1 hour

Correct answer: D

Rationale: Acrocyanosis, a bluish discoloration of the hands and feet, is a normal finding in newborns within the first few hours after birth. The heart rate of 130 beats per minute is also within the normal range for a newborn. These findings are typical and do not require immediate intervention. The appropriate action for the nurse is to continue monitoring the newborn. Reassessing the newborn in 1 hour allows the nurse to observe any changes and ensure the newborn's condition remains stable. Placing the newborn under a radiant warmer or applying oxygen is not necessary as the newborn's condition is within normal limits. Swaddling the newborn may provide comfort but is not the priority action in this scenario.

4. A nurse is assessing a client who has a sodium level of 122 mEq/L. Which of the following findings should the nurse expect?

• A. Decreased deep tendon reflexes
• B. Positive Trousseau’s sign
• C. Hypoactive bowel sounds
• D. Sticky mucous membranes

Correct answer: A

Rationale: A sodium level of 122 mEq/L indicates hyponatremia, which is characterized by decreased deep tendon reflexes. Hyponatremia leads to neurological symptoms such as altered reflexes. Choices B, C, and D are not typically associated with hyponatremia. Positive Trousseau’s sign is related to hypocalcemia, hypoactive bowel sounds can be seen in paralytic ileus or decreased peristalsis, and sticky mucous membranes are not specific findings related to sodium imbalances.

5. A nurse is providing teaching to a client who has tuberculosis (TB) and is prescribed rifampin. Which of the following statements should the nurse include in the teaching?

• A. This medication can cause your urine to turn a reddish-orange color.
• B. You should expect to take this medication for at least 6 months.
• C. You should avoid eating dairy products while on this medication.
• D. This medication can cause sensitivity to sunlight.

Correct answer: A

Rationale: The correct answer is A. Rifampin can cause harmless red-orange discoloration of bodily fluids, including urine, sweat, and tears. Clients should be informed about this side effect. Choice B is incorrect because the duration of rifampin therapy for TB is typically longer than 6 months. Choice C is incorrect as there is no need to avoid dairy products while on rifampin. Choice D is incorrect as rifampin does not cause sensitivity to sunlight.

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