Nursing Elites

1. A client has a new prescription for metformin. Which of the following statements should the nurse include in the teaching?

• A. Take the medication with a full glass of water.
• B. Monitor for signs of hypoglycemia.
• C. Increase your fluid intake.
• D. Expect a metallic taste in your mouth.

Correct answer: C

Rationale: Increasing fluid intake is an important teaching point for clients starting metformin to prevent gastrointestinal discomfort, a common side effect of this medication. Metformin can cause gastrointestinal symptoms such as nausea, bloating, and diarrhea, which can be reduced by staying well-hydrated. Therefore, advising the client to increase their fluid intake will help minimize these side effects and improve medication tolerance. The other options are incorrect: Option A is a general instruction for taking medications but not specifically related to metformin. Option B is incorrect because metformin typically does not cause hypoglycemia but rather hyperglycemia. Option D is also incorrect as a metallic taste in the mouth is not a common side effect of metformin.

2. A client with a diagnosis of myocardial infarction has a new activity prescription allowing the client to have bathroom privileges. As the client stands and begins to walk, the client begins to complain of chest pain. The nurse should take which action?

• A. Assist the client to get back into bed.
• B. Report the chest pain episode to the healthcare provider.
• C. Tell the client to stand still and take the client's blood pressure.
• D. Give a nitroglycerin (Nitrostat) tablet and assist the client to the bathroom.

Correct answer: A

Rationale: In a client with myocardial infarction experiencing chest pain during activity, the priority action is to stop the activity immediately to reduce the heart's workload and oxygen demand. Assisting the client back to bed helps in reducing stress on the heart and can prevent worsening of the condition. Reporting the chest pain episode to the healthcare provider is important but should not delay taking immediate action to alleviate symptoms. Taking the client's blood pressure and administering nitroglycerin are secondary actions after ensuring the client's safety and comfort. Therefore, the correct action is to assist the client back into bed.

3. The nurse is caring for a client with coronary artery disease (CAD) who reports chest pain. The nurse administers nitroglycerin as prescribed. What is the next priority action?

• A. Obtain a 12-lead ECG
• B. Monitor the client's blood pressure
• C. Notify the healthcare provider
• D. Administer a second dose of nitroglycerin

Correct answer: B

Rationale: After administering nitroglycerin, the next priority action is to monitor the client's blood pressure. Nitroglycerin can cause vasodilation and subsequent hypotension, so it is crucial to assess the client's blood pressure to prevent complications and ensure safety. Obtaining a 12-lead ECG may be necessary but monitoring blood pressure takes precedence to detect and manage potential hypotension. Notifying the healthcare provider can be done after ensuring the client's stability. Administering a second dose of nitroglycerin without assessing the client's response and blood pressure can lead to further hypotension.

4. A healthcare professional is assessing a client who is taking digoxin. Which of the following findings should the healthcare professional report to the provider?

• A. Weight gain
• B. Dry cough
• C. Hypokalemia
• D. Bradycardia

Correct answer: D

Rationale: Bradycardia is a significant finding in a client taking digoxin as it is a sign of digoxin toxicity. Bradycardia can indicate that the client is experiencing an adverse reaction to the medication, potentially leading to serious complications. Therefore, it is crucial for the healthcare professional to report bradycardia to the provider promptly for further evaluation and intervention. Weight gain, dry cough, and hypokalemia are not typically associated with digoxin toxicity and may have other underlying causes. While weight gain and cough can be monitored, bradycardia requires immediate attention due to its potential link to digoxin toxicity.

5. The client with heart failure is prescribed furosemide (Lasix). Which electrolyte imbalance is the nurse most likely to monitor for?

• A. Hyperkalemia
• B. Hypernatremia
• C. Hypokalemia
• D. Hyponatremia

Correct answer: C

Rationale: The correct answer is C: Hypokalemia. Furosemide, a loop diuretic, commonly causes potassium loss, leading to hypokalemia. The nurse should closely monitor for decreased potassium levels in a client receiving furosemide to prevent complications such as cardiac arrhythmias or muscle weakness. Hyperkalemia (Choice A) is not typically associated with furosemide use. Hypernatremia (Choice B) refers to high sodium levels and is not the primary concern with furosemide. Hyponatremia (Choice D) is low sodium levels, which can occur but is less common than hypokalemia in clients taking furosemide.

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