Nursing Elites

1. The client is receiving digoxin (Lanoxin) for heart failure. Which symptom would indicate digoxin toxicity?

• A. Increased appetite
• B. Yellow or blurred vision
• C. Increased urination
• D. Diarrhea

Correct answer: B

Rationale: Yellow or blurred vision can be a sign of digoxin toxicity. These visual disturbances are concerning as they indicate a potential adverse reaction to the medication. Recognizing this symptom promptly is crucial to prevent serious complications. Increased appetite, increased urination, and diarrhea are not typically associated with digoxin toxicity. Therefore, option B is the correct choice in this scenario.

2. A client is scheduled for a coronary artery bypass graft (CABG) surgery. The nurse should prepare the client by reinforcing information about which post-operative care measure?

• A. You will be on bed rest for the first 48 hours after surgery.
• B. You will be encouraged to cough and deep breathe frequently.
• C. You will be discharged within 24 hours if no complications arise.
• D. You will not be able to eat or drink for 24 hours after surgery.

Correct answer: B

Rationale: Encouraging the client to cough and deep breathe frequently is essential post-operative care to prevent respiratory complications such as atelectasis and pneumonia after CABG surgery. Choices A, C, and D are incorrect because post-CABG surgery, early mobilization is encouraged to prevent complications such as deep vein thrombosis (DVT) and pneumonia. Discharge within 24 hours is unlikely after CABG surgery, and early oral intake is encouraged to promote recovery and prevent complications.

3. The client has been prescribed warfarin (Coumadin) and is being educated about dietary restrictions. Which food should the client be advised to avoid or eat in consistent amounts?

• A. Bananas
• B. Spinach
• C. Oranges
• D. Yogurt

Correct answer: B

Rationale: Spinach is high in vitamin K, which can interfere with the effectiveness of warfarin. It is important for clients taking warfarin to maintain consistent levels of vitamin K intake to ensure the medication works properly. Foods rich in vitamin K, such as spinach, can counteract the effects of warfarin, leading to potential complications. Therefore, clients on warfarin are advised to either avoid or consume vitamin K-rich foods, like spinach, in consistent amounts to maintain the medication's efficacy. Bananas, oranges, and yogurt are not high in vitamin K and do not significantly impact the effectiveness of warfarin, making them safe options for clients taking this medication.

4. The nurse is assisting with the care of a client who is on a continuous heparin infusion for deep vein thrombosis (DVT). Which laboratory test should the nurse monitor to evaluate the effectiveness of the therapy?

• A. Prothrombin time (PT)
• B. Activated partial thromboplastin time (aPTT)
• C. International normalized ratio (INR)
• D. Platelet count

Correct answer: B

Rationale: To evaluate the effectiveness of heparin therapy in a client with DVT, the nurse should monitor the activated partial thromboplastin time (aPTT). The aPTT test helps ensure that the dose of heparin is within the therapeutic range, which is essential for preventing clot formation or excessive bleeding. Monitoring aPTT is crucial in managing patients on heparin therapy to maintain the delicate balance between preventing thrombosis and avoiding hemorrhage. Prothrombin time (PT) and International normalized ratio (INR) are more indicative of warfarin therapy effectiveness, not heparin. Platelet count assesses platelet levels and function, not the effectiveness of heparin therapy for DVT.

5. The healthcare provider is teaching a client with hypertension about lifestyle modifications. Which recommendation should the healthcare provider include?

• A. Limit alcohol consumption to one drink per day.
• B. Increase sodium intake to maintain blood pressure.
• C. Exercise vigorously for at least 30 minutes daily.
• D. Avoid high potassium foods like bananas.

Correct answer: A

Rationale: Limiting alcohol intake is an essential lifestyle modification recommended for managing hypertension. Excessive alcohol consumption can raise blood pressure, so limiting it to one drink per day is beneficial in controlling hypertension. Alcohol moderation is a key part of a heart-healthy lifestyle for individuals with high blood pressure. Choice B is incorrect because increasing sodium intake can actually worsen hypertension by retaining water and increasing blood pressure. Choice C is incorrect because while exercise is important for overall health, moderate-intensity exercise is recommended for individuals with hypertension to avoid excessive strain on the heart. Choice D is incorrect because high potassium foods like bananas are actually beneficial for individuals with hypertension as they can help lower blood pressure.

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