Nursing Elites

1. When starting therapy with trastuzumab, which finding should the nurse instruct the client to report?

• A. Dyspnea
• B. Constipation
• C. Tinnitus
• D. Dry mouth

Correct answer: A

Rationale: The correct answer is A: Dyspnea. Dyspnea can indicate pulmonary toxicity, a severe adverse effect of trastuzumab. It is crucial for the client to report any breathing difficulties promptly to ensure timely intervention and prevent further complications. Choices B, C, and D are incorrect because constipation, tinnitus, and dry mouth are not commonly associated with trastuzumab therapy and are not indicative of serious adverse effects that require immediate attention.

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 nurse is teaching a client who has a new prescription for Hydralazine. Which of the following adverse effects should the nurse instruct the client to monitor?

• A. Tachycardia
• B. Hyperglycemia
• C. Hyponatremia
• D. Constipation

Correct answer: A

Rationale: Corrected Rationale: Hydralazine is a vasodilator that can cause reflex tachycardia as an adverse effect. The client should monitor their pulse and report any significant increases. Choice B, Hyperglycemia, is not a common adverse effect of Hydralazine. Choice C, Hyponatremia, and Choice D, Constipation, are also not typically associated with Hydralazine use.

4. When does regular insulin typically peak?

• A. 30 minutes to 2 ½ hours
• B. 1 to 3 hours
• C. 6 to 14 hours
• D. 1 to 5 hours

Correct answer: D

Rationale: Regular insulin usually peaks around 1 to 5 hours after administration. This peak time frame is important to consider when managing blood glucose levels and timing meals to coincide with insulin activity. Choice A, '30 minutes to 2 ½ hours,' is incorrect because regular insulin typically peaks later. Choice B, '1 to 3 hours,' is not the most accurate as the peak for regular insulin can extend beyond 3 hours. Choice C, '6 to 14 hours,' is incorrect as this timeframe is more indicative of long-acting insulins, not regular insulin.

5. A client is prescribed Nitroglycerin sublingual tablets. Which of the following instructions should the nurse include during discharge teaching?

• A. Take the medication with food.
• B. Store the medication in a cool, dry place.
• C. Swallow the tablets whole.
• D. Take one tablet every 5 minutes up to three doses for chest pain.

Correct answer: D

Rationale: During a chest pain episode, the client should take one nitroglycerin tablet sublingually every 5 minutes up to a total of three doses. If chest pain persists after three doses, emergency medical attention should be sought. Nitroglycerin should not be swallowed but allowed to dissolve under the tongue for rapid absorption. Storing the medication in a cool, dry place helps maintain its effectiveness.

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