Nursing Elites

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

• A. Take the medication in the morning.
• B. Monitor for muscle weakness.
• C. Eat foods high in potassium.
• D. Expect weight gain.

Correct answer: C

Rationale: The correct statement that the nurse should include in the teaching for a client prescribed furosemide is to eat foods high in potassium. Furosemide can lead to potassium depletion (hypokalemia) due to increased urine output. Consuming potassium-rich foods like bananas, oranges, spinach, and potatoes can help prevent this electrolyte imbalance. Choices A, B, and D are incorrect because taking furosemide in the morning, monitoring for muscle weakness, and expecting weight gain are not directly related to the potential side effects or necessary dietary adjustments when taking furosemide.

2. The client with a history of angina pectoris reports chest pain unrelieved by nitroglycerin. Which action should the nurse take next?

• A. Administer another dose of nitroglycerin.
• B. Notify the healthcare provider immediately.
• C. Have the client lie down and rest.
• D. Encourage the client to take deep breaths.

Correct answer: B

Rationale: When a client with a history of angina pectoris reports chest pain unrelieved by nitroglycerin, it may indicate a myocardial infarction, also known as a heart attack. In this situation, the nurse should immediately notify the healthcare provider to ensure prompt evaluation and appropriate intervention. Delay in seeking medical attention for chest pain unrelieved by nitroglycerin can be life-threatening, as it might be a sign of a more serious cardiac event. Administering another dose of nitroglycerin (Choice A) without further evaluation can be risky, as the client's condition may require a different intervention. Having the client lie down and rest (Choice C) or encouraging deep breaths (Choice D) are not appropriate actions in this scenario where a more serious cardiac event needs to be ruled out.

3. A client with a diagnosis of angina pectoris is prescribed nitroglycerin tablets. How should the nurse instruct the client to take the medication?

• A. Swallow the tablet whole with water
• B. Place the tablet under the tongue and let it dissolve
• C. Chew the tablet and then swallow
• D. Place the tablet between the cheek and gum

Correct answer: B

Rationale: Nitroglycerin is most effective when administered sublingually (under the tongue) as it is rapidly absorbed into the bloodstream. Placing the tablet under the tongue allows for quick absorption and faster relief of angina symptoms. Chewing the tablet, swallowing it, or placing it between the cheek and gum would not provide the same rapid onset of action needed during an angina episode. Therefore, the correct instruction for the client is to place the nitroglycerin tablet under the tongue and let it dissolve for optimal effectiveness.

4. A client with a diagnosis of acute myocardial infarction (MI) is receiving thrombolytic therapy. The nurse monitors the client for which potential complication associated with this therapy?

• A. Hypertension
• B. Bleeding
• C. Hyperkalemia
• D. Hypoglycemia

Correct answer: B

Rationale: Thrombolytic therapy is associated with an increased risk of bleeding due to its mechanism of action in dissolving blood clots. Therefore, the nurse should closely monitor the client for any signs of hemorrhage, such as unexplained bruising, bleeding gums, or blood in the urine or stools. Hypertension is not a common complication of thrombolytic therapy. Hyperkalemia and hypoglycemia are also not typically associated with this therapy.

5. The healthcare professional is assessing a client who presents with jaundice. Which assessment finding is most important for the healthcare professional to follow up on?

• A. Urine specific gravity of 1.03
• B. Frothy, tea-colored urine
• C. Clay-colored stools
• D. Elevated serum amylase and lipase levels

Correct answer: D

Rationale: Elevated serum amylase and lipase levels are indicative of pancreatitis, a serious condition that can manifest with jaundice. Timely follow-up is crucial to manage pancreatitis and its complications effectively in a jaundiced client. Choices A, B, and C are less critical in this scenario. Urine specific gravity within normal range, frothy tea-colored urine, and clay-colored stools can be associated with various conditions but are not directly indicative of pancreatitis, which is the most concerning condition associated with jaundice.

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