Nursing Elites

1. A client has a new prescription for a Fentanyl transdermal patch. Which of the following instructions should the nurse include?

• A. Apply the patch to a non-hairy area.
• B. Change the patch every 72 hours.
• C. Avoid exposure to heat sources.
• D. Do not cut the patch to adjust the dosage.

Correct answer: C

Rationale: The correct instruction the nurse should include for a client using a Fentanyl transdermal patch is to avoid exposure to heat sources. Heat can increase the absorption of the medication, potentially causing an overdose. Instructing the client to avoid heat sources is crucial to ensure their safety and the effectiveness of the medication. Choices A, B, and D are incorrect because applying the patch to a non-hairy area, changing it every 72 hours, and not cutting the patch are general guidelines for using transdermal patches but do not specifically address the unique risks associated with Fentanyl patches.

2. 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.

3. A client in labor is receiving IV Opioid analgesics. Which of the following actions should the nurse take?

• A. Instruct the client to self-ambulate every 2 hours.
• B. Offer oral hygiene every 2 hours.
• C. Anticipate medication administration 2 hours prior to delivery.
• D. Monitor fetal heart rate every 2 hours.

Correct answer: B

Rationale: When a client is receiving IV Opioid analgesics during labor, the nurse should offer oral hygiene every 2 hours. Opioid analgesics can cause adverse effects like dry mouth, nausea, and vomiting. Providing oral hygiene care helps alleviate these symptoms and maintains the client's comfort and well-being during labor. Instructing the client to self-ambulate every 2 hours is not appropriate during labor as mobility may be limited. Anticipating medication administration 2 hours prior to delivery is not necessary as the timing of medication administration should be based on the client's needs and the progress of labor. Monitoring fetal heart rate every 2 hours is important during labor, but it is not specifically related to the client receiving IV Opioid analgesics.

4. A client has a new prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include?

• A. Take one tablet at the first sign of chest pain.
• B. If pain is not relieved, take another tablet in 10 minutes.
• C. You can take up to five tablets in 15 minutes.
• D. Swallow the tablet with water.

Correct answer: A

Rationale: The correct instruction for a client with a new prescription for nitroglycerin sublingual tablets is to take one tablet at the first sign of chest pain. If the pain persists after 5 minutes, the client should call 911 and take a second tablet. Choice A is correct because taking one tablet at the onset of chest pain helps to relieve symptoms by dilating blood vessels and improving blood flow to the heart. Choices B and C are incorrect as they suggest taking multiple tablets without waiting for the initial dose to take effect, which can lead to hypotension and other adverse effects. Choice D is incorrect as nitroglycerin sublingual tablets should not be swallowed but instead placed under the tongue for rapid absorption.

5. When teaching a client with a new prescription for Sulfasalazine, which instruction should the nurse include?

• A. Expect orange discoloration of urine and skin.
• B. Increase your intake of high-sodium foods.
• C. Take the medication with a full glass of milk.
• D. Expect your stools to be black and tarry.

Correct answer: A

Rationale: The correct instruction to include when teaching a client with a new prescription for Sulfasalazine is to expect orange discoloration of urine and skin. Sulfasalazine can cause this harmless side effect, which does not necessitate discontinuation of the medication. It is crucial for the nurse to educate the client about this expected outcome to prevent unnecessary concern or discontinuation of the medication. Choices B, C, and D are incorrect. Increasing intake of high-sodium foods is not recommended with Sulfasalazine, as it can worsen certain side effects. Taking the medication with a full glass of milk is not necessary for Sulfasalazine administration. Expecting stools to be black and tarry is not an expected side effect of Sulfasalazine.

Similar Questions