Nursing Elites

1. A client with atrial fibrillation is receiving warfarin (Coumadin). The nurse should reinforce which instruction?

• A. Avoid foods high in vitamin K.
• B. Increase intake of dairy products.
• C. Limit intake of high-fiber foods.
• D. Avoid protein-rich foods.

Correct answer: A

Rationale: The correct answer is A: Avoid foods high in vitamin K. Clients taking warfarin need to be cautious with their vitamin K intake because vitamin K can counteract the effects of the medication. Therefore, it is essential to avoid foods high in vitamin K to maintain the therapeutic effects of warfarin. Choice B is incorrect because increasing dairy product intake is not specifically related to warfarin therapy. Choice C is incorrect as high-fiber foods do not interfere with warfarin therapy. Choice D is incorrect as protein-rich foods are not contraindicated with warfarin therapy.

2. The client will wear a Holter monitor for continuous cardiac monitoring over the next 24 hours. What action should the nurse take to assist the client?

• A. Shave the front of the client's chest
• B. Give the client a device holder to wear around the waist
• C. Teach the client to rest as much as possible during the next 24 hours
• D. Tell the client to cover the monitor in plastic wrap before taking a bath

Correct answer: B

Rationale: Providing the client with a device holder to wear around the waist allows them to comfortably carry the Holter monitor while engaging in normal activities throughout the 24-hour monitoring period. This approach supports the client's mobility and ensures the monitor is securely in place for accurate readings. Shaving the front of the client's chest is unnecessary and not a standard practice for Holter monitor placement. Instructing the client to rest as much as possible does not promote normal daily activities which are important for accurate monitoring. Covering the monitor in plastic wrap before bathing is not recommended as it may affect the functionality of the device.

3. A client has a history of left-sided heart failure. The nurse should look for the presence of which finding to determine whether the problem is currently active?

• A. Presence of ascites
• B. Bilateral lung crackles
• C. Jugular vein distention
• D. Pedal edema bilaterally

Correct answer: B

Rationale: When assessing a client with a history of left-sided heart failure, the presence of bilateral lung crackles is a key finding to determine if the condition is currently active. Crackles in the lungs indicate fluid accumulation, a common sign of left-sided heart failure due to pulmonary congestion. Choices A, C, and D are incorrect because ascites, jugular vein distention, and pedal edema are more commonly associated with right-sided heart failure.

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

• A. Take the medication in the morning.
• B. Avoid consuming grapefruit juice.
• C. Take the medication with a full glass of water.
• D. Monitor for signs of weight gain.

Correct answer: C

Rationale: When a client is prescribed amitriptyline, it is important to instruct them to take the medication with a full glass of water. This instruction helps prevent esophageal irritation, as amitriptyline can be harsh on the esophagus. Option C is the correct choice. Option A, taking the medication in the morning, is not specific to amitriptyline and can vary depending on the individual's condition. Option B, avoiding grapefruit juice, is a general precaution for many medications but not specifically related to amitriptyline. Option D, monitoring for signs of weight gain, is not a direct instruction for taking the medication itself and may not be a common side effect of amitriptyline.

5. A client with a diagnosis of angina pectoris is prescribed nitroglycerin. The nurse should teach the client to take the medication in which way?

• A. Take one tablet daily with breakfast
• B. Take one tablet every 5 minutes as needed, up to three times
• C. Take one tablet every hour until pain subsides
• D. Take one tablet only if pain does not subside after 30 minutes

Correct answer: B

Rationale: Nitroglycerin is a rapid-acting medication used to relieve angina pain by dilating blood vessels. The correct administration is to take one tablet every 5 minutes as needed, up to three doses. This dosing regimen helps in managing acute angina episodes effectively. Choice A is incorrect because nitroglycerin is not taken once daily. Choice C is incorrect because waiting for an hour between doses may not provide timely relief during angina attacks. Choice D is incorrect as it suggests waiting for 30 minutes before taking another dose, which could delay symptom relief in acute situations.

Similar Questions