Which medication should the nurse administer first after receiving the morning shift report?

The statin medication to the client diagnosed with atherosclerosis

The antiplatelet medication for the client who had a myocardial infarction.

The IVPB antibiotic was administered to the client diagnosed with endocarditis, admitted at 0530 today.

The coronary vasodilator patch to the client diagnosed with coronary artery disease.

Answer and Explanation

The Correct Answer is C

Infective endocarditis involves a microbial infection of the endocardial surface, typically targeting the cardiac valves and resulting in the formation of friable vegetations. These lesions can lead to valvular incompetence, myocardial abscesses, or systemic septic embolization. Rapid initiation of high-dose intravenous therapy is mandatory to achieve bactericidal concentrations and prevent irreversible valvular destruction or sudden hemodynamic collapse.

Rationale:

A. Statin medications, or HMG-CoA reductase inhibitors, are utilized for the long-term management of hyperlipidemia and the stabilization of atherosclerotic plaques. While they are critical for preventing future cardiovascular events, they do not provide acute stabilization or immediate life-saving effects. Administering this medication is a routine task that can be deferred until after higher-priority treatments are completed.

B. Antiplatelet therapy is a standard secondary prevention strategy used to inhibit thrombocyte aggregation and reduce the risk of recurrent ischemic events following a myocardial infarction. Although essential for maintaining vascular patency, it is typically a daily maintenance medication in the post-acute phase. It does not take precedence over the first dose of a time-critical antibiotic for an active infection.

C. The first dose of an antibiotic for acute endocarditis is a medical priority to halt the progression of valvular damage and systemic sepsis. Early administration is linked to improved clinical outcomes and a reduction in the risk of embolic complications. This medication must be given immediately after admission to establish a therapeutic window and control the infectious process in the bloodstream.

D. Coronary vasodilator patches, such as nitroglycerin, are used for the prophylactic management of chronic stable angina by reducing myocardial oxygen demand. While important for managing coronary artery disease, the patch is a slow-release delivery system intended for long-term symptom control rather than acute intervention. It is a lower priority compared to the urgent antimicrobial needs of a newly admitted client.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["A","C","D"]

Explanation

A surgical ophthalmic care environment requires prioritization based on nursing scope of practice, task delegation principles, patient acuity, and educational versus technical interventions, ensuring the RN performs complex assessment, teaching, and postoperative clinical judgment functions while delegating routine tasks appropriately within a team-based model.

Rationale:

A. This involves postoperative education requiring clinical assessment of understanding, reinforcement of discharge instructions, and evaluation of potential complications after cataract surgery. RN-level responsibility is appropriate because it requires critical thinking and individualized teaching based on surgical outcomes.

B. This task involves basic nursing care that is procedural and repetitive, such as applying an eye patch. It can be delegated to assistive personnel. It does not require RN assessment or clinical judgment, making it inappropriate for RN assignment in team-based care.

C. This task involves medication administration requiring knowledge of ocular pharmacology, correct instillation technique, and monitoring for adverse effects such as intraocular pressure changes or irritation. RN responsibility is appropriate due to required clinical competency and safety monitoring.

D. This involves patient education for self-administration of ophthalmic drops, requiring evaluation of learning readiness, demonstration return, and correction of technique. RN-level critical thinking is needed to ensure safe long-term self-management and adherence to therapeutic regimen.

E. This involves preoperative teaching, which is an RN responsibility; however, in team assignment prioritization, it is less acute than immediate postoperative teaching or medication administration. While appropriate for RN scope, it is not prioritized over higher acuity postoperative needs.

A. The client with a history of asthma who is being treated for acute asthma exacerbation. B. The client admitted for wound care to the left lower extremity after wound debridement. C. The client transferred from the progressive unit who is to be discharged the next day. D. The client who is transferred to the unit 2 hours after an open appendectomy. E. The client who requires frequent assessments after a change in their level of consciousness.

Correct Answer is ["B","C","D"]

Explanation

Effective delegation is based on the scope of practice and the stability of the client’s physiological status. Licensed Practical Nurses (LPNs) are qualified to care for clients with stable, predictable outcomes and perform standardized procedures such as wound care and monitoring post-operative progress. The Registered Nurse (RN) must retain responsibility for clients requiring complex clinical judgment, initial assessments of instability, or frequent evaluations of a deteriorating neurological status.

Rationale:

A. An acute asthma exacerbation is an unstable respiratory condition that can rapidly progress to status asthmaticus or respiratory failure. This client requires continuous assessment of lung sounds, work of breathing, and the potential for titrating emergency medications. Because the outcome is currently unpredictable, this client must remain under the direct care of an RN.

B. Wound care following a debridement is a standardized nursing procedure that falls within the LPN’s scope of practice. The client’s condition is relatively stable, and the treatment plan involves established protocols for infection control and dressing changes. The LPN is well-trained to observe the wound bed for healing and report any significant changes to the RN.

C. A client who is ready for discharge the following day is considered physiologically stable. The nursing care focuses on reinforcing previous education and completing routine tasks. Since the acute phase of their illness has passed and their response to treatment is well-documented, they are an appropriate assignment for an LPN.

D. Two hours after an open appendectomy, a client has typically bypassed the immediate post-anesthesia recovery risks. While they require monitoring for pain and surgical site integrity, their care follows a predictable postoperative pathway. LPNs can safely monitor vital signs and surgical dressings for clients who have achieved initial stability following uncomplicated procedures.

E. A change in the level of consciousness (LOC) indicates a potentially life-threatening neurological or metabolic crisis. This client requires high-level assessment skills and rapid clinical reasoning to identify the underlying etiology. Because the situation is acutely unstable and requires frequent, complex evaluations, it cannot be delegated to an LPN.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which medication should the nurse administer first after receiving the morning shift report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The registered nurse (RN) is the leader of a team on a unit that utilizes a team approach. Which clients should the RN care for? Select All That Apply

Correct Answer is ["A","C","D"]

Explanation

The licensed practical nurse has been pulled to the medical surgical unit to take clients. Which clients should the charge nurse delegate to the licensed practical nurse? Select All That Apply.

Correct Answer is ["B","C","D"]

Explanation

The Emergency Department nurse is admitting a 58-year-old client with atypical chest pain. Which actions would the nurse delegate to the experienced unlicensed assistive personnel? Select All That Apply.

A nurse is caring for a client being transferred from an acute care setting to a long-term care facility. Which information should the nurse include in the transfer report? Select All That Apply.

A new nurse manager plans to examine the staff's interprofessional collaboration skills. Which actions by staff should the nurse anticipate to promote interprofessional collaboration? Select All That Apply.

An unlicensed assistive personnel (UAP) reports to the nurse that a client was found on the floor. Which action should the nurse do after ensuring the client's safety?

The charge nurse on the cardiac unit is counseling a staff nurse because the nurse has clocked in late multiple times for the 7:00 a.m. to 7:00 p.m. shift. Which conflict resolution uses the win-win strategy?

A nurse is planning care for a client who requires bilateral arm restraints because the client is delirious and attempting to pull out a urinary retention catheter. Which information is important to consider when planning care for this client? Select All That Apply.

A nurse accuses a newly licensed nurse of providing inadequate care for a client who underwent hip arthroplasty. Which response by the newly licensed nurse demonstrates assertiveness?

A nurse is studying the recent increase in Type II diabetes in the community. Which factors should the nurse consider when examining the development of disease? Select All That Apply.