Nursing Elites

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

• A. Take the medication with food.
• B. Expect red-orange discoloration of body fluids.
• C. Monitor for signs of hyperglycemia.
• D. Avoid consuming dairy products.

Correct answer: B

Rationale: The correct answer is to inform the client to expect red-orange discoloration of body fluids when taking rifampin. Rifampin is known to cause this side effect, which is harmless but can be surprising to patients. It is important for the nurse to educate the client about this expected change to prevent unnecessary concern or alarm. Monitoring for hyperglycemia is not directly related to rifampin, and taking the medication with food or avoiding dairy products are not specific instructions for this medication.

2. The client is being ambulated due to activity intolerance caused by bacterial endocarditis. How can the nurse determine that the client is best tolerating ambulation?

• A. Mild dyspnea after walking 10 feet
• B. Minimal chest pain rated 1 on a 1-to-10 pain scale
• C. Pulse rate that increases from 68 to 94 beats per minute
• D. Blood pressure that increases from 114/82 to 118/86 mm Hg

Correct answer: D

Rationale: A slight increase in blood pressure without significant symptoms indicates that the client is tolerating the activity. In this scenario, a mild increase in blood pressure without other symptoms is a positive sign of tolerance to ambulation despite the underlying condition of bacterial endocarditis. Choices A, B, and C are not the best indicators of tolerance to ambulation in this case. Mild dyspnea after walking a short distance, minimal chest pain, and an increase in pulse rate are common signs that the activity might not be well-tolerated by the client with a history of bacterial endocarditis.

3. Why should the client diagnosed with rheumatic heart disease be advised to notify the dentist before dental procedures?

• A. The client requires prophylactic antibiotics before treatment.
• B. The client may experience dysrhythmias with high-speed drills.
• C. The client may have an adverse reaction to lidocaine with epinephrine.
• D. The client may develop heart failure during stressful events.

Correct answer: A

Rationale: Clients with rheumatic heart disease are at risk for infective endocarditis, a serious infection of the heart lining or valves. They need prophylactic antibiotics before invasive procedures, including dental work, to prevent this life-threatening complication. While dysrhythmias with high-speed drills, adverse reactions to local anesthesia, and the risk of heart failure during stressful events are all concerns for clients with heart conditions, the primary reason for notifying the dentist before dental procedures in rheumatic heart disease is the need for prophylactic antibiotics to prevent infective endocarditis.

4. A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit with cardiac monitoring via telemetry. The nurse assisting in caring for the client expects to note which type of activity prescribed?

• A. Strict bed rest for 24 hours
• B. Bathroom privileges and self-care activities
• C. Unrestricted activities because the client is monitored
• D. Unsupervised hallway ambulation with distances less than 200 feet

Correct answer: B

Rationale: After being transferred from the CCU to the general medical unit with cardiac monitoring, the client with MI is typically prescribed bathroom privileges and self-care activities. This approach allows for gradual recovery and mobility while still being closely monitored, promoting the client's overall well-being and independence. Choice A, strict bed rest for 24 hours, is too restrictive and not recommended for MI patients as it can lead to complications like deep vein thrombosis. Choice C, unrestricted activities, is also not appropriate as MI patients usually require monitoring and gradual re-introduction to activities. Choice D, unsupervised hallway ambulation with distances less than 200 feet, may be too strenuous for a client who just got transferred from the CCU and needs a more gradual approach to activity.

5. The nurse is caring for a client who has undergone a coronary artery bypass graft (CABG) surgery. Which action should the nurse take to prevent postoperative complications?

• A. Encourage the client to cough and deep breathe every 1 to 2 hours.
• B. Maintain the client in a supine position at all times.
• C. Keep the client on bed rest for the first 48 hours.
• D. Restrict the client's fluid intake to prevent overload.

Correct answer: A

Rationale: Encouraging the client to cough and deep breathe every 1 to 2 hours is crucial post-CABG surgery to prevent respiratory complications, such as atelectasis and pneumonia. These actions help to expand lung volume, clear secretions, and prevent the collapse of alveoli. Choices B, C, and D are incorrect because maintaining the client in a supine position at all times can lead to complications like decreased lung expansion, keeping the client on bed rest for the first 48 hours may increase the risk of thromboembolism, and restricting fluid intake postoperatively can lead to dehydration and electrolyte imbalances.

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