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

• A. You should have your white blood cell count checked regularly.
• B. You should take this medication on an empty stomach.
• C. You should avoid eating foods high in tyramine.
• D. You should avoid taking this medication with milk.

Correct answer: A

Rationale: The correct answer is A: 'You should have your white blood cell count checked regularly.' Clozapine can lead to agranulocytosis, a serious condition characterized by a low white blood cell count. Regular monitoring of the white blood cell count is crucial to detect this adverse effect early and prevent serious complications. Choices B, C, and D are incorrect because taking clozapine on an empty stomach, avoiding foods high in tyramine, or avoiding taking the medication with milk are not specific instructions related to the potential adverse effect of agranulocytosis associated with clozapine.

3. When teaching a client about the use of lisinopril, which of the following instructions should the nurse include?

• A. Monitor your blood pressure regularly.
• B. Take the medication with food.
• C. Increase your intake of potassium-rich foods.
• D. Avoid grapefruit juice.

Correct answer: A

Rationale: The correct answer is to instruct the client to monitor their blood pressure regularly when taking lisinopril. Lisinopril is known to cause hypotension, so monitoring blood pressure is crucial to ensure it stays within a safe range. This monitoring helps in early detection of any potential issues related to low blood pressure, allowing for timely intervention. Choices B, C, and D are incorrect because taking lisinopril with food, increasing potassium-rich foods intake, and avoiding grapefruit juice are not specific instructions related to the safe and effective use of lisinopril.

4. A client who had a myocardial infarction (MI) two days ago reports chest pain radiating to the left arm. What should the nurse do immediately?

• A. Administer morphine
• B. Obtain an electrocardiogram (ECG)
• C. Apply oxygen via nasal cannula
• D. Administer sublingual nitroglycerin

Correct answer: B

Rationale: Obtaining an ECG is crucial in this situation because it helps in assessing for potential complications, such as a recurrent MI or ongoing ischemia. This diagnostic test provides valuable information to guide further interventions and treatment. Administering morphine, oxygen, or nitroglycerin may be necessary but obtaining an ECG takes precedence to evaluate the cardiac status and determine the appropriate course of action. Administering morphine without assessing the current cardiac status through an ECG can mask important diagnostic clues. Applying oxygen and administering nitroglycerin are supportive measures that can follow the ECG to address potential hypoxia and ischemic pain relief, respectively.

5. The healthcare provider is reinforcing dietary instructions to a client with coronary artery disease who has been prescribed a low-cholesterol diet. The healthcare provider should advise the client to choose which food item?

• A. Whole milk
• B. Oatmeal with fresh fruit
• C. Fried chicken
• D. Bacon and eggs

Correct answer: B

Rationale: Oatmeal with fresh fruit is the correct choice for a client with coronary artery disease on a low-cholesterol diet. Oatmeal is a heart-healthy option that is low in cholesterol and saturated fats. Fresh fruits are also a good source of essential nutrients and fiber. Choices A, C, and D are not suitable for a low-cholesterol diet. Whole milk, fried chicken, bacon, and eggs are high in cholesterol and saturated fats, which can be detrimental to individuals with coronary artery disease.

Similar Questions