Nursing Elites

1. A client with a history of hypertension is being discharged on a low-sodium diet. Which statement by the client indicates a need for further teaching?

• A. I will use fresh herbs and spices instead of salt.
• B. I will avoid canned soups and processed foods.
• C. I can eat as much bacon and sausage as I want because they taste good.
• D. I will read food labels to check for sodium content.

Correct answer: C

Rationale: Choice C is the correct answer because bacon and sausage are high in sodium, which contradicts the low-sodium diet requirement. Consuming them freely would contribute to increased sodium intake, which is not suitable for managing hypertension. Choices A, B, and D demonstrate appropriate understanding and actions for a low-sodium diet, such as using alternatives to salt, avoiding processed foods, and checking food labels for sodium content.

2. The nurse is caring for a client with hypertension who is prescribed a thiazide diuretic. The nurse should check which parameter before administering the medication?

• A. Serum potassium level
• B. Blood pressure
• C. Heart rate
• D. Serum sodium level

Correct answer: B

Rationale: Before administering a thiazide diuretic to a client with hypertension, the nurse should check the blood pressure. Thiazide diuretics are prescribed to lower blood pressure, so assessing the client's blood pressure prior to administration helps to monitor the effectiveness of the medication and to ensure the client's safety. Checking the serum potassium level (Choice A), heart rate (Choice C), or serum sodium level (Choice D) are also important parameters in the care of a client on a thiazide diuretic, but the priority assessment before administering the medication is the blood pressure to evaluate the drug's effectiveness in managing hypertension.

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

• A. Take the medication with a full glass of water.
• B. Avoid consuming dairy products.
• C. Take the medication on an empty stomach.
• D. Expect a metallic taste in your mouth.

Correct answer: B

Rationale: The correct instruction for a client prescribed phenytoin is to avoid consuming dairy products. Dairy products can reduce the absorption of phenytoin. Taking the medication with a full glass of water (Choice A) is generally a good practice for oral medications but is not specifically required for phenytoin. Taking the medication on an empty stomach (Choice C) can lead to gastrointestinal upset, so it is not recommended for phenytoin. Expecting a metallic taste in the mouth (Choice D) is a possible side effect of phenytoin but is not a crucial instruction for the client to follow.

4. A client reports chest pain that is unrelieved by three doses of nitroglycerin taken 5 minutes apart. What is the nurse's next best action?

• A. Administer another dose of nitroglycerin.
• B. Call the healthcare provider immediately.
• C. Provide oxygen via nasal cannula.
• D. Place the client in a supine position.

Correct answer: B

Rationale: In the scenario described, the client's chest pain persists despite three doses of nitroglycerin, indicating a potentially severe cardiac issue like a myocardial infarction. The priority for the nurse in this situation is to involve the healthcare provider promptly. Calling the healthcare provider immediately is essential to ensure timely evaluation and appropriate intervention for the client. Administering more nitroglycerin without further assessment or instructions may not be safe and could delay necessary treatments. Providing oxygen or changing the client's position may offer some comfort but does not address the underlying potentially life-threatening condition, making these options less appropriate as the immediate next best action.

5. A client is receiving heparin therapy. Which of the following laboratory tests should be monitored to evaluate the effectiveness of the therapy?

• A. Prothrombin time (PT)
• B. International normalized ratio (INR)
• C. Activated partial thromboplastin time (aPTT)
• D. Complete blood count (CBC)

Correct answer: C

Rationale: Activated partial thromboplastin time (aPTT) is the most appropriate laboratory test to monitor the effectiveness of heparin therapy. Heparin works on the intrinsic pathway of the coagulation cascade, and monitoring aPTT helps assess its anticoagulant effect. Therapeutic levels of aPTT for clients on heparin therapy are typically 1.5 to 2.5 times the control value. Prothrombin time (PT) and International normalized ratio (INR) are used to monitor warfarin therapy, which acts on the extrinsic pathway of the coagulation cascade. Complete blood count (CBC) is not specific for monitoring the effectiveness of heparin therapy.

Similar Questions