Nursing Elites

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

• A. Avoid foods high in potassium.
• B. Report a pulse rate less than 60 beats per minute.
• C. Take the medications in the morning.
• D. Weigh yourself daily.

Correct answer: B

Rationale: The correct answer is B. The nurse should instruct the client to report a pulse rate less than 60 beats per minute, as it could indicate digoxin toxicity. Consuming potassium-rich foods is encouraged due to the potential for furosemide (Lasix) to cause hypokalemia. The medications should be taken in the morning to prevent nocturia. Weighing oneself daily is important to monitor for fluid retention, a crucial aspect in managing heart failure. Therefore, choices A, C, and D are incorrect as they do not address the specific teaching point related to digoxin and its potential toxicity.

2. A client with a prescription to take theophylline (Theo-24) daily has been given medication instructions by the nurse. The nurse determines that the client needs further information about the medication if the client states that he or she will:

• A. Drink at least 2 L of fluid per day.
• B. Take the daily dose at bedtime.
• C. Avoid changing brands of the medication without health care provider (HCP) approval.
• D. Avoid over-the-counter (OTC) cough and cold medications unless approved by the HCP.

Correct answer: B

Rationale: The correct answer is B. Taking theophylline at bedtime is inappropriate because it can cause insomnia. The medication should be taken early in the morning to avoid disrupting sleep patterns. It is important to follow the healthcare provider's instructions regarding the timing of the medication to achieve optimal therapeutic effects.

3. A client with chronic pain is prescribed transdermal fentanyl (Duragesic) patches. Which instruction should the nurse include in the teaching plan?

• A. Apply the patch to a different site each time.
• B. Avoid using heating pads over the patch.
• C. Change the patch every 72 hours.
• D. Remove the old patch before applying the new one.

Correct answer: B

Rationale: Clients using transdermal fentanyl (Duragesic) patches should avoid using heating pads over the patch as heat can increase the release of the medication, potentially leading to overdose. The patch should be applied to a different site each time, changed every 72 hours, and the old patch should be removed before applying a new one to prevent accidental overdose or excessive drug absorption.

4. A client is prescribed atorvastatin (Lipitor) for hyperlipidemia. Which instruction should the nurse include in the teaching plan?

• A. Take the medication in the morning.
• B. Avoid consuming grapefruit juice.
• C. Increase intake of dairy products.
• D. Take the medication with food.

Correct answer: B

Rationale: The correct instruction for the nurse to include in the teaching plan is to advise the client to avoid consuming grapefruit juice. Grapefruit juice can increase the risk of atorvastatin (Lipitor) toxicity by inhibiting its metabolism. Atorvastatin is typically taken in the evening because cholesterol synthesis occurs at night. Increasing dairy intake is not specifically recommended for atorvastatin use, and the medication can be taken with or without food.

5. A clinic nurse prepares to administer an MMR (measles, mumps, rubella) vaccine to a child. How is this vaccine best administered?

• A. Intramuscularly in the deltoid muscle
• B. Subcutaneously in the gluteal muscle
• C. Subcutaneously in the outer aspect of the upper arm
• D. Intramuscularly in the anterolateral aspect of the thigh

Correct answer: C

Rationale: The MMR vaccine is best administered subcutaneously in the outer aspect of the upper arm. This route allows for proper absorption and efficacy of the vaccine while minimizing the risk of injury or discomfort to the child.

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