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. A client with a history of coronary artery disease (CAD) is prescribed simvastatin (Zocor). The nurse should teach the client about which potential side effect?

• A. Muscle pain
• B. Dry mouth
• C. Drowsiness
• D. Diarrhea

Correct answer: A

Rationale: Muscle pain is a common side effect of statins like simvastatin and can indicate a serious condition called rhabdomyolysis. Rhabdomyolysis is a severe condition where muscle fibers break down rapidly, releasing myoglobin into the bloodstream, which can lead to kidney damage. Therefore, it's important for the nurse to educate the client about this potential side effect and to promptly report any muscle pain to the healthcare provider. Dry mouth, drowsiness, and diarrhea are not commonly associated with simvastatin use and are less concerning compared to the risk of rhabdomyolysis.

3. A nurse is assessing a client who is taking hydrocodone. Which of the following findings should the nurse report to the provider?

• A. Constipation
• B. Sedation
• C. Dry mouth
• D. Respiratory depression

Correct answer: D

Rationale: The correct answer is D: Respiratory depression. Hydrocodone is an opioid medication that can cause respiratory depression, a serious side effect that should be reported immediately to the healthcare provider. Constipation, sedation, and dry mouth are common side effects of hydrocodone but are not as concerning as respiratory depression. Constipation can be managed with lifestyle modifications and medications, sedation may improve with time or dosage adjustments, and dry mouth is a common and usually benign side effect.

4. The client with chronic stable angina is prescribed a beta blocker. The nurse is reinforcing instructions. What instruction should the nurse include?

• A. Take the medication with a meal.
• B. Report a pulse rate below 60 beats per minute.
• C. Discontinue the medication if dizziness occurs.
• D. Avoid drinking grapefruit juice.

Correct answer: B

Rationale: The correct instruction for the nurse to include is to advise the client to report a pulse rate below 60 beats per minute. Beta blockers are known to lower heart rate, and a pulse rate below 60 beats per minute may indicate bradycardia, a condition that requires medical attention. Option A, 'Take the medication with a meal,' is incorrect because beta blockers don't necessarily need to be taken with food. Option C, 'Discontinue the medication if dizziness occurs,' is incorrect because abrupt cessation of beta blockers can lead to rebound hypertension and other adverse effects. Option D, 'Avoid drinking grapefruit juice,' is unrelated to beta blockers' mechanism of action or side effects.

5. The LPN/LVN is assisting in caring for a client in the telemetry unit who is receiving an intravenous infusion of 1000 mL of 5% dextrose with 40 mEq of potassium chloride. Which occurrence observed on the cardiac monitor indicates the presence of hyperkalemia?

• A. Tall, peaked T waves
• B. ST segment depressions
• C. Shortened P-R intervals
• D. Shortening of the QRS complex

Correct answer: A

Rationale: In hyperkalemia, tall, peaked T waves are a distinct ECG finding. These T waves can be seen as a result of increased serum potassium levels, affecting the repolarization phase of the cardiac action potential. It is crucial for healthcare providers to recognize this ECG change promptly as hyperkalemia can lead to serious cardiac arrhythmias and complications. ST segment depressions, shortened P-R intervals, and shortening of the QRS complex are not typically associated with hyperkalemia. ST segment depressions are more indicative of myocardial ischemia or infarction. Shortened P-R intervals may be seen in conditions like Wolff-Parkinson-White syndrome. Shortening of the QRS complex is associated with conditions affecting the conduction system of the heart, such as bundle branch blocks.

Similar Questions