Nursing Elites

1. A nurse is providing discharge teaching to a client who has a prescription for digoxin. Which of the following instructions should the nurse include?

• A. Take your pulse before taking the medication.
• B. Take the medication with an antacid.
• C. Double the dose if you miss one.
• D. Take the medication with a high-fiber meal.

Correct answer: A

Rationale: The correct answer is A: 'Take your pulse before taking the medication.' When administering digoxin, it is crucial to monitor the pulse rate because digoxin can cause bradycardia (slow heart rate). Checking the pulse helps in assessing the heart rate before taking the medication, as bradycardia is a common side effect of digoxin. Choice B is incorrect because digoxin should not be taken with antacids, as they can reduce its absorption. Choice C is incorrect; the dose should never be doubled if a dose is missed. Choice D is incorrect because taking digoxin with a high-fiber meal can also affect its absorption. Therefore, the essential instruction for the client is to monitor the pulse before taking digoxin.

2. A client has a stage 1 pressure ulcer on the right heel. Which of the following interventions should the nurse include in the plan?

• A. Apply a heat lamp to the area for 20 minutes each day.
• B. Change the dressing on the heel every 12 hours.
• C. Apply a transparent dressing over the heel.
• D. Use a water pressure mattress.

Correct answer: C

Rationale: Applying a transparent dressing over the heel is beneficial as it can protect the ulcer from friction and shear, and allow for continuous observation of the wound. This intervention promotes healing and prevents further damage to the skin. Choice A is incorrect because applying heat can increase the risk of tissue damage and should be avoided. Choice B is incorrect as changing the dressing every 12 hours may disrupt the wound healing process and is not necessary for a stage 1 pressure ulcer. Choice D is incorrect because using a water pressure mattress is not a specific intervention for a stage 1 pressure ulcer on the heel.

3. What is the primary purpose of therapeutic communication in healthcare?

• A. To gather client information.
• B. To provide client education.
• C. To establish a therapeutic relationship.
• D. To document client care.

Correct answer: C

Rationale: The primary purpose of therapeutic communication in healthcare is to establish a therapeutic relationship between the healthcare provider and the client. Through effective communication, trust, empathy, and understanding can be fostered, which are essential for providing quality care and promoting positive health outcomes. Building a therapeutic relationship enhances patient satisfaction, improves adherence to treatment plans, and increases the likelihood of successful health outcomes.

4. A client has been on bed rest for 3 days. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?

• A. The client uses a walker to move from the bed to the chair.
• B. The client has a strong cough.
• C. The client can bear weight on both legs.
• D. The client has a normal respiratory rate.

Correct answer: C

Rationale: The ability to bear weight on both legs indicates muscle strength and stability necessary for ambulation. This skill is crucial for the client to support their body weight and move independently when standing or walking. Choices A, B, and D are incorrect because using a walker, having a strong cough, or having a normal respiratory rate do not directly indicate the readiness to ambulate. The key factor in determining readiness for ambulation is the client's ability to bear weight on both legs, demonstrating the necessary strength for standing and walking.

5. A client has a new diagnosis of lactose intolerance and is receiving teaching from a nurse about dietary management. Which of the following statements should the nurse include in the teaching?

• A. You should avoid foods that contain lactose.
• B. You should increase your intake of high-fiber foods.
• C. You should avoid foods that contain gluten.
• D. You should increase your intake of dairy products.

Correct answer: A

Rationale: The correct statement for the nurse to include in teaching a client with lactose intolerance is to avoid foods that contain lactose. Lactose intolerance results from the body's inability to digest lactose, a sugar found in dairy products. By avoiding foods containing lactose, the client can manage symptoms and prevent complications associated with lactose intolerance. Choices B, C, and D are incorrect. Increasing intake of high-fiber foods (choice B) may be beneficial for general health but is not directly related to lactose intolerance. Avoiding gluten (choice C) is necessary for individuals with celiac disease, not lactose intolerance. Increasing intake of dairy products (choice D) would worsen symptoms in individuals with lactose intolerance due to the lactose content.

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