Nursing Elites

1. A client with a history of coronary artery disease (CAD) is being discharged with a prescription for aspirin. Which instruction should the nurse reinforce with the client?

• A. Take the aspirin on an empty stomach for better absorption.
• B. Stop taking the aspirin if you experience any stomach discomfort.
• C. Take the aspirin with food to reduce the risk of stomach irritation.
• D. Take the aspirin only when you have chest pain.

Correct answer: C

Rationale: The correct instruction is to take the aspirin with food to reduce the risk of stomach irritation. This is crucial for clients with a history of coronary artery disease as it helps minimize gastrointestinal side effects like irritation and bleeding. Option A is incorrect because aspirin should not be taken on an empty stomach to prevent stomach upset. Option B is incorrect because discontinuing aspirin at the first sign of stomach discomfort can be harmful, and a healthcare provider should be consulted instead. Option D is incorrect because aspirin is often prescribed for prevention in cardiovascular conditions, not just for chest pain relief.

2. The client with diabetes mellitus has gangrene of the toes to the midfoot. Which goal should be included in this client's plan of care?

• A. Restore skin integrity.
• B. Prevent infection.
• C. Promote healing.
• D. Improve nutrition.

Correct answer: B

Rationale: Preventing infection is crucial in clients with gangrene to halt the spread of infection and avert further complications. Infections can exacerbate tissue damage and lead to systemic complications, making infection prevention a priority in the care plan for this client. Restoring skin integrity and promoting healing may not be achievable goals until the infection is under control. Improving nutrition is important for overall health but may not be the priority when the immediate concern is preventing infection.

3. A client with a history of heart failure is admitted with a diagnosis of pulmonary edema. Which intervention should the LPN/LVN expect to assist with first?

• A. Administer a diuretic as prescribed.
• B. Place the client in a high Fowler's position.
• C. Prepare the client for intubation.
• D. Insert an indwelling urinary catheter.

Correct answer: B

Rationale: In a client with pulmonary edema, placing them in a high Fowler's position is the priority intervention. This position helps to improve ventilation and oxygenation by decreasing venous return, reducing the workload on the heart, and facilitating fluid redistribution from the lungs. It is crucial to optimize respiratory function and oxygenation before considering other interventions like administering medications, preparing for intubation, or inserting a urinary catheter. Administering a diuretic, preparing for intubation, or inserting a urinary catheter may be necessary but should follow the priority of improving oxygenation through positioning.

4. When preparing to administer a controlled substance, which of the following actions is required?

• A. Check the client's identification bracelet.
• B. Check the client's allergy status.
• C. Have a second nurse witness disposal of the medication.
• D. Document the administration in the client's medical record.

Correct answer: C

Rationale: When administering controlled substances, it is crucial to have a second nurse witness the disposal of the medication. This measure ensures proper handling, reduces the risk of diversion, and promotes compliance with regulations regarding controlled substances. Having a second nurse witness the disposal is a safeguard to maintain accountability and prevent any potential misuse or errors during the disposal process. Checking the client's identification bracelet and allergy status are important steps in medication administration but are not specifically required for controlled substances. Documenting the administration in the client's medical record is essential but does not specifically relate to the disposal of controlled substances.

5. A client with chronic heart failure has been prescribed furosemide (Lasix). Which instruction should the nurse reinforce to the client regarding this medication?

• A. Take the medication with food.
• B. Limit foods high in potassium while taking this medication.
• C. Report any muscle cramps or weakness to your healthcare provider.
• D. Expect to urinate more frequently while on this medication.

Correct answer: C

Rationale: The correct instruction for the nurse to reinforce to the client regarding furosemide (Lasix) is to report any muscle cramps or weakness to the healthcare provider. Muscle cramps or weakness may indicate hypokalemia, a potential side effect of furosemide. Monitoring and reporting these symptoms promptly can help in preventing complications related to electrolyte imbalances. Choice A is incorrect because furosemide should be taken on an empty stomach. Choice B is not directly related to furosemide use; in fact, foods high in potassium may be beneficial for clients taking furosemide to prevent hypokalemia. Choice D is a common expected side effect of furosemide due to its diuretic action but is not as crucial to report as potential signs of electrolyte imbalances.

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