Nursing Elites

1. A client with heart failure is prescribed digoxin (Lanoxin). Which instruction should the nurse include in the client's teaching plan?

• A. Take your pulse before each dose and hold the medication if your pulse is below 60 beats per minute.
• B. Increase your intake of foods high in potassium.
• C. Take the medication with a high-fiber meal to enhance absorption.
• D. Skip a dose if you feel dizzy or lightheaded.

Correct answer: A

Rationale: The correct instruction for a client prescribed digoxin is to take their pulse before each dose and hold the medication if the pulse is below 60 beats per minute. This is crucial to prevent digoxin toxicity, as digoxin can cause adverse effects when the pulse rate is too low. Monitoring the pulse regularly ensures safety and appropriate management of the medication.

2. A 55-year-old woman presents with fatigue, pruritus, and jaundice. Laboratory tests reveal elevated bilirubin and alkaline phosphatase levels. Imaging shows dilated intrahepatic bile ducts and a normal common bile duct. What is the most likely diagnosis?

• A. Primary biliary cirrhosis
• B. Primary sclerosing cholangitis
• C. Gallstones
• D. Pancreatic cancer

Correct answer: A

Rationale: The presentation of fatigue, pruritus, and jaundice in a 55-year-old woman, along with elevated bilirubin and alkaline phosphatase levels, and imaging findings of dilated intrahepatic bile ducts and a normal common bile duct, are characteristic of primary biliary cirrhosis. Primary biliary cirrhosis is an autoimmune liver disease that typically affects middle-aged women, leading to progressive destruction of the intrahepatic bile ducts.

3. A male client is admitted to the neurological unit. He has just sustained a C-5 spinal cord injury. Which assessment finding of this client warrants immediate intervention by the nurse?

• A. Is unable to feel sensation in the arms and hands.
• B. Has flaccid upper and lower extremities.
• C. Blood pressure is 110/70 and the apical pulse is 68.
• D. Respirations are shallow, labored, and 14 breaths/minute.

Correct answer: D

Rationale: Respirations that are shallow, labored, and at 14 breaths/minute indicate potential respiratory compromise, which is a critical situation requiring immediate intervention to maintain adequate oxygenation and prevent respiratory failure.

4. A patient with type 2 diabetes is prescribed metformin. What instruction should the nurse provide regarding this medication?

• A. Take the medication on an empty stomach.
• B. Monitor for signs of hypoglycemia.
• C. Take the medication with meals.
• D. Increase intake of simple carbohydrates.

Correct answer: C

Rationale: The correct instruction for a patient prescribed metformin is to take the medication with meals. This helps reduce gastrointestinal side effects commonly associated with metformin. Patients should also be educated about the signs of lactic acidosis, a rare but serious side effect associated with metformin use.

5. An outcome for treatment of peripheral vascular disease is, 'The client will have decreased venous congestion.' What client behavior would indicate to the nurse that this outcome has been met?

• A. Avoids prolonged sitting or standing.
• B. Avoids trauma and irritation to skin.
• C. Wears protective shoes.
• D. Quits smoking.

Correct answer: A

Rationale: The correct answer is A: 'Avoids prolonged sitting or standing.' In clients with peripheral vascular disease, decreased venous congestion is a desired outcome. Avoiding prolonged sitting or standing helps improve venous return and reduces congestion in the lower extremities, contributing to the achievement of this treatment goal.

Similar Questions