Nursing Elites

1. The healthcare provider is preparing to assist in the care of a client who has just returned from coronary artery bypass graft (CABG) surgery. Which is the priority action?

• A. Monitor the client's urine output.
• B. Check the client's surgical dressing.
• C. Measure the client's blood pressure.
• D. Assess the client's level of consciousness.

Correct answer: D

Rationale: Assessing the client's level of consciousness is the priority action post-CABG surgery to monitor for signs of cerebral hypoxia or other complications that require immediate intervention. Changes in the client's level of consciousness can indicate neurological deterioration, which is critical to address promptly in this postoperative period. Monitoring urine output, checking surgical dressing, and measuring blood pressure are important aspects of postoperative care but assessing the client's level of consciousness takes precedence as it provides crucial information about the client's neurological status and the need for urgent intervention.

2. A nurse is assessing a client who has a new prescription for enalapril. Which of the following findings is a priority for the nurse to report to the provider?

• A. Frequent urination
• B. Dry cough
• C. Tremors
• D. Dizziness

Correct answer: D

Rationale: The correct answer is D: Dizziness. Dizziness is a sign of hypotension, a potential adverse effect of enalapril. Enalapril is an ACE inhibitor commonly prescribed for hypertension. Hypotension is a serious side effect that can lead to complications such as falls and injuries. Reporting dizziness promptly is crucial to prevent any harm to the client. Choices A, B, and C are not directly associated with enalapril use and are less concerning compared to the potential implications of hypotension indicated by dizziness.

3. A client with known coronary artery disease (CAD) begins to experience chest pain while getting out of bed. What action should the nurse take?

• A. Obtain a prescription for pain medication.
• B. Have the client stop and lie back down in bed.
• C. Report the complaint to the healthcare provider.
• D. Instruct the client to continue getting out of bed and into a chair.

Correct answer: B

Rationale: When a client with CAD experiences chest pain, it indicates myocardial ischemia. The nurse should have the client stop the activity and lie back down in bed to reduce the heart's oxygen demand, decrease myocardial workload, and prevent further ischemia. This action helps in improving blood flow to the heart and can potentially alleviate the chest pain. Option A is incorrect as pain medication should not be the initial action for chest pain in CAD. Option C is incorrect because the nurse should first intervene directly to address the chest pain. Option D is incorrect as continuing the activity can worsen the myocardial ischemia and chest pain.

4. A client with a diagnosis of heart failure is prescribed spironolactone (Aldactone). Which laboratory value should the nurse monitor closely?

• A. Serum calcium
• B. Serum potassium
• C. Serum sodium
• D. Serum glucose

Correct answer: B

Rationale: The correct answer is B: Serum potassium. Spironolactone is a potassium-sparing diuretic, which can lead to hyperkalemia. Monitoring serum potassium levels is crucial to prevent potential complications related to high potassium levels, such as cardiac arrhythmias. Therefore, close monitoring of serum potassium is essential for clients taking spironolactone. Choices A, C, and D are incorrect because spironolactone does not directly impact serum calcium, sodium, or glucose levels significantly. While these values may be monitored for other reasons in a client with heart failure, they are not the primary focus of monitoring when spironolactone is prescribed.

5. A client has a new prescription for isoniazid. Which of the following instructions should the nurse include?

• A. Take the medication on an empty stomach.
• B. Avoid drinking alcohol.
• C. Take the medication with an antacid.
• D. Increase your intake of leafy green vegetables.

Correct answer: B

Rationale: The correct answer is to instruct the client to avoid drinking alcohol. Isoniazid can cause liver damage, and alcohol consumption can increase this risk. Therefore, it is crucial to avoid alcohol while taking isoniazid to prevent potential liver complications. Choice A is incorrect because isoniazid is typically taken with food to reduce gastrointestinal upset. Choice C is incorrect because antacids can decrease the absorption of isoniazid. Choice D is incorrect as there is no specific recommendation to increase leafy green vegetable intake when taking isoniazid.

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