Nursing Elites

1. A client admitted with coronary artery disease (CAD) reports dyspnea at rest. What intervention should the nurse prioritize?

• A. Providing a walker to aid in ambulation
• B. Elevating the head of the bed to at least 45 degrees
• C. Performing continuous monitoring of oxygen saturation
• D. Placing an oxygen cannula at the bedside for use if needed

Correct answer: B

Rationale: In a client with coronary artery disease (CAD) experiencing dyspnea at rest, the priority intervention should be to elevate the head of the bed to at least 45 degrees. This position helps reduce the work of breathing, optimizes lung expansion, and can alleviate symptoms of dyspnea by improving oxygenation and ventilation. Providing a walker for ambulation, monitoring oxygen saturation, and having an oxygen cannula at the bedside are important interventions but not the priority when the client is experiencing dyspnea at rest. Elevating the head of the bed is crucial to improve respiratory function and should be prioritized in this situation.

2. A nurse is assessing a client who has been taking phenytoin for epilepsy. Which of the following findings should the nurse report to the provider?

• A. Weight loss
• B. Gingival hyperplasia
• C. Increased thirst
• D. Frequent urination

Correct answer: B

Rationale: The correct answer is B: Gingival hyperplasia. Phenytoin is known to cause gingival hyperplasia, an overgrowth of gum tissue, which can lead to oral health issues and requires dental care. Choices A, C, and D are not directly associated with phenytoin use. Weight loss, increased thirst, and frequent urination are not typically reported findings related to phenytoin and should not be prioritized over gingival hyperplasia when assessing a client taking this medication.

3. The patient with a history of myocardial infarction (MI) is prescribed aspirin. What instruction should the nurse include in the discharge teaching?

• A. Take the aspirin with food to prevent gastrointestinal upset
• B. Discontinue the aspirin if experiencing ringing in the ears
• C. Take the aspirin at bedtime to minimize side effects
• D. Avoid taking aspirin if also taking other NSAIDs

Correct answer: A

Rationale: Taking aspirin with food is recommended to prevent gastrointestinal irritation and upset, which are common side effects of aspirin. It helps protect the stomach lining and reduce the risk of developing ulcers. This instruction is crucial in promoting medication adherence and minimizing discomfort for the patient. Choices B, C, and D are incorrect because discontinuing aspirin without consulting a healthcare provider, taking it at bedtime, or avoiding it if taking other NSAIDs can have negative consequences on the patient's health and treatment plan.

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

• A. Take the medication with or without food.
• B. Monitor for signs of hypokalemia.
• C. Increase your intake of potassium-rich foods.
• D. Expect an increase in urination.

Correct answer: D

Rationale: The correct instruction to include when a client is prescribed furosemide is to expect an increase in urination. Furosemide is a diuretic that works by increasing urine production, so it is essential for the client to anticipate and understand this effect. Monitoring for signs of hypokalemia and increasing potassium-rich foods are not directly related to furosemide use. Hypokalemia is a potential side effect of furosemide, so monitoring for it is crucial. Increasing potassium-rich foods can help counteract potassium loss due to diuretic use. Taking furosemide with food is not required, as it can be taken with or without food.

5. A client with a history of heart failure is being discharged with a prescription for digoxin (Lanoxin). The nurse should include which instruction in the discharge teaching?

• A. Take your pulse before each dose and hold the medication if your pulse is below 60 beats per minute.
• B. Increase your fluid intake to at least 3 liters per day.
• C. Report any weight loss of more than 2 pounds in a week.
• D. Take the medication with meals to avoid gastrointestinal upset.

Correct answer: A

Rationale: The correct instruction for discharge teaching regarding digoxin (Lanoxin) is to advise the client to take their pulse before each dose and to hold the medication if their pulse is below 60 beats per minute. Digoxin can cause bradycardia, so monitoring the pulse is crucial to prevent potential complications. Choice B is incorrect because excessive fluid intake can lead to fluid overload, worsening heart failure. Choice C is not directly related to digoxin therapy. Choice D is inaccurate as digoxin is usually taken on an empty stomach to facilitate absorption.

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