Nursing Elites

1. The nurse is preparing a client for discharge after a myocardial infarction (MI). Which instruction is most important for the nurse to reinforce with the client?

• A. Avoid engaging in sexual activity for at least 6 weeks.
• B. Engage in moderate physical activity daily.
• C. Take prescribed medications even if you feel well.
• D. Return to work only when medically cleared.

Correct answer: C

Rationale: The most critical instruction for a client after a myocardial infarction is to continue taking prescribed medications even if they feel well. This is essential in preventing another myocardial infarction or other complications. Discontinuing medications prematurely can be detrimental to the client's recovery and may increase the risk of further cardiovascular events. Choices A, B, and D are incorrect because engaging in sexual activity, physical activity, or returning to work are important aspects of the client's recovery, but not as crucial as ensuring medication compliance to prevent further cardiac issues.

2. A client being seen in the emergency department for complaints of chest pain confides in the nurse about regular use of cocaine as a recreational drug. The nurse takes which important action in delivering holistic nursing care to this client?

• A. Reports the client to the police for illegal drug use
• B. Explains to the client the damage that cocaine does to the heart
• C. Tells the client it is imperative to stop before myocardial infarction occurs
• D. Teaches about the effects of cocaine on the heart and offers a referral for further help

Correct answer: D

Rationale: In this scenario, the nurse should prioritize educating the client about the effects of cocaine on the heart and provide a referral for further help. This approach is crucial in addressing the root cause of the client's health issues and supporting them in making informed decisions about their health. Reporting the client to the police is not appropriate in this situation as the focus should be on the client's health and well-being. Simply explaining the damage without offering solutions may not effectively address the client's needs or promote holistic care. Telling the client to stop without providing support or education may not be as effective as teaching about the effects of cocaine and offering help for cessation. Therefore, educating about the effects and providing a referral for further assistance is the best course of action for holistic nursing care.

3. A client with a history of chronic heart failure is being discharged. Which instruction should the nurse include in the discharge teaching?

• A. Weigh yourself daily and report a weight gain of 2 pounds or more in a day.
• B. Restrict fluid intake to 2000 mL per day.
• C. Increase your salt intake to prevent electrolyte imbalance.
• D. Exercise vigorously at least three times a week.

Correct answer: A

Rationale: The correct answer is to weigh yourself daily and report a weight gain of 2 pounds or more in a day. This instruction is crucial because daily weights help in early detection of fluid retention, a common complication in heart failure. Monitoring weight is essential for managing heart failure and preventing exacerbations. Choice B is incorrect because fluid restriction may be necessary in some cases of heart failure, but a general limit of 2000 mL per day is not appropriate without individual assessment. Choice C is incorrect as increasing salt intake can worsen fluid retention and exacerbate heart failure symptoms. Choice D is incorrect because while exercise is beneficial for heart health, vigorous exercise may not be suitable for all heart failure patients and should be tailored to their specific condition.

4. The healthcare provider is preparing to administer a calcium channel blocker to a client with hypertension. What parameter should be checked before administering the medication?

• A. Apical pulse
• B. Serum calcium level
• C. Blood pressure
• D. Respiratory rate

Correct answer: C

Rationale: Before administering a calcium channel blocker to a client with hypertension, the healthcare provider should check the client's blood pressure. Calcium channel blockers are used to lower blood pressure, making it essential to assess the current blood pressure to ensure it is within the appropriate range for administration. Checking the apical pulse (choice A) is not the priority before administering a calcium channel blocker, as the focus should be on blood pressure. Serum calcium level (choice B) is not directly related to the administration of calcium channel blockers for hypertension. Respiratory rate (choice D) is not the primary parameter to check before administering a calcium channel blocker in this scenario.

5. The nurse is caring for a client who has returned to the unit after undergoing a cardiac catheterization. The nurse should monitor for which common complication following this procedure?

• A. Hypertension
• B. Hypotension
• C. Hemorrhage
• D. Hyperglycemia

Correct answer: C

Rationale: Following a cardiac catheterization, a common complication to monitor for is bleeding or hemorrhage at the catheter insertion site. Hemorrhage is a significant concern due to the potential for rapid blood loss, leading to hypovolemic shock and other serious complications. Monitoring for signs of bleeding, such as swelling, hematoma, or drop in hemoglobin levels, is crucial for timely intervention. Hypertension is not a common complication post-cardiac catheterization; instead, hypotension may occur due to vasovagal response or bleeding. Hyperglycemia is not typically associated with cardiac catheterization unless the client has pre-existing diabetes or stress-induced hyperglycemia.

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