Nursing Elites

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

• A. You may experience weight gain.
• B. Increase your intake of vitamin K.
• C. Expect increased urinary output.
• D. You may have dark, tarry stools.

Correct answer: A

Rationale: The correct answer is A. Weight gain is a common side effect of prednisone. The nurse should educate the client about the possibility of weight gain and the need to monitor it closely during treatment with prednisone. Choice B is incorrect because increasing vitamin K intake is not specifically related to prednisone therapy. Choice C is incorrect as prednisone is more likely to cause fluid retention rather than increased urinary output. Choice D is incorrect as dark, tarry stools are not a common side effect of prednisone.

2. A client is taking haloperidol. Which of the following findings should the nurse report to the provider?

• A. Weight gain
• B. Dry mouth
• C. Tremors
• D. Tardive dyskinesia

Correct answer: D

Rationale: The correct answer is D: Tardive dyskinesia. Tardive dyskinesia is a serious side effect associated with the long-term use of haloperidol. It is characterized by involuntary movements of the face, tongue, and extremities. Early detection is crucial as tardive dyskinesia may be irreversible and should be reported promptly to the healthcare provider for further evaluation and management. Choices A, B, and C are incorrect because weight gain, dry mouth, and tremors are common side effects of haloperidol but are not as concerning as tardive dyskinesia. While they should still be monitored and managed, tardive dyskinesia requires immediate attention due to its potentially irreversible nature.

3. The LPN/LVN is assisting in the care of a client who has been prescribed enoxaparin (Lovenox) for the prevention of deep vein thrombosis (DVT). Which instruction should the nurse reinforce with the client?

• A. Avoid consuming foods high in vitamin K while taking this medication.
• B. Administer the injection in the same site each time for consistency.
• C. Report any unusual bleeding or bruising to your healthcare provider.
• D. Do not take aspirin if you experience any mild pain or discomfort.

Correct answer: C

Rationale: The correct instruction for the nurse to reinforce with the client is to report any unusual bleeding or bruising to their healthcare provider. This is crucial because unusual bleeding or bruising may indicate excessive anticoagulation, a potential side effect of enoxaparin. Prompt reporting to a healthcare provider is necessary to prevent complications. Choices A, B, and D are incorrect. Choice A is not directly related to enoxaparin and vitamin K interactions. Choice B is incorrect as rotating injection sites is essential for preventing tissue damage and irritation. Choice D is also incorrect as aspirin can increase the risk of bleeding when taken with enoxaparin.

4. The client with heart failure is receiving digoxin (Lanoxin). The nurse should monitor the client for which sign of digoxin toxicity?

• A. Hypertension
• B. Bradycardia
• C. Hyperglycemia
• D. Insomnia

Correct answer: B

Rationale: Bradycardia is a common sign of digoxin toxicity. Digoxin can cause disturbances in the heart's electrical conduction system, leading to a slower heart rate. Therefore, the nurse should closely monitor the client's heart rate for signs of bradycardia, which could indicate digoxin toxicity. Hypertension (Choice A), hyperglycemia (Choice C), and insomnia (Choice D) are not typically associated with digoxin toxicity. Therefore, they are incorrect choices for this question.

5. 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.

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