Nursing Elites

1. A healthcare provider is planning to administer IV Alteplase to a client who is demonstrating manifestations of a massive Pulmonary Embolism. Which of the following interventions should the healthcare provider plan to take?

• A. Administer IM Enoxaparin along with the Alteplase dose.
• B. Hold direct pressure on puncture sites for up to 30 minutes.
• C. Administer Aminocaproic acid IV prior to alteplase infusion.
• D. Prepare to administer Alteplase within 8 hours of manifestation onset.

Correct answer: B

Rationale: When administering IV Alteplase for a massive Pulmonary Embolism, the healthcare provider should plan to hold direct pressure on puncture sites for 10 to 30 minutes or until oozing of blood stops. This is crucial to prevent bleeding complications at the puncture sites. Choice A is incorrect because Enoxaparin is not usually administered along with Alteplase for a Pulmonary Embolism. Choice C is incorrect because Aminocaproic acid is not typically given prior to alteplase infusion in this situation. Choice D is incorrect because Alteplase should be administered within 2 hours of onset of manifestations for Pulmonary Embolism, not within 8 hours.

2. When assessing a client with chronic Neutropenia receiving Filgrastim, what action should the nurse take to evaluate for an adverse effect of the medication?

• A. Assess for bone pain.
• B. Assess for right lower quadrant pain.
• C. Auscultate for crackles in the bases of the lungs.
• D. Auscultate the chest to listen for a heart murmur.

Correct answer: A

Rationale: The correct action when assessing a client receiving Filgrastim for chronic Neutropenia is to assess for bone pain. Bone pain is a known dose-related adverse effect of Filgrastim. Acetaminophen or opioid analgesics can be used to manage bone pain if necessary. Assessing for other types of pain, lung crackles, or heart murmurs would not be specific to the adverse effects of Filgrastim.

3. A client has a new prescription for Atenolol. Which of the following instructions should be included by the healthcare provider?

• A. Take this medication in the morning.
• B. Monitor your heart rate regularly.
• C. Avoid foods high in potassium.
• D. Increase your fluid intake.

Correct answer: B

Rationale: The correct answer is B. Atenolol is a beta-blocker that can cause bradycardia, leading to a decreased heart rate. Monitoring heart rate regularly is essential to detect any significant decreases promptly and seek medical attention. While choices A, C, and D may be relevant to the client's overall health, monitoring heart rate is the priority instruction due to the nature of Atenolol's effects. Taking the medication in the morning can be individualized based on the client's needs and preferences. Avoiding foods high in potassium and increasing fluid intake are generally beneficial but not directly related to managing the side effects of Atenolol.

4. A client has been taking Sertraline for the past 2 days. Which of the following assessment findings should alert the nurse to the possibility that the client is developing Serotonin syndrome?

• A. Bruising
• B. Fever
• C. Abdominal pain
• D. Rash

Correct answer: B

Rationale: Fever is a key symptom of serotonin syndrome, a potentially serious condition that can occur with the use of SSRIs like Sertraline. Serotonin syndrome is characterized by excessive levels of serotonin in the body, leading to symptoms such as fever, agitation, confusion, tremors, and sweating. If a client on Sertraline presents with fever, the nurse should consider the possibility of serotonin syndrome and take appropriate actions such as notifying the healthcare provider and monitoring the client closely. Bruising, abdominal pain, and rash are not typically associated with serotonin syndrome and are more likely to be indicative of other conditions or side effects.

5. How should the oral form of albuterol be taken?

• A. Administer with meals to minimize gastric irritation
• B. Administer before meals with water
• C. Administer after meals with water
• D. Administer in the morning with milk

Correct answer: A

Rationale: The correct way to take oral albuterol is with meals to minimize gastric irritation. Taking it with food can help reduce the risk of stomach upset that may occur when the medication is taken on an empty stomach. This approach can improve tolerability and adherence to the treatment regimen. Choices B, C, and D are incorrect because taking albuterol before meals, after meals, or in the morning with milk does not address the issue of minimizing gastric irritation, which is a common side effect of the medication.

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