Nursing Elites

1. A client diagnosed with angina pectoris returns to the nursing unit after experiencing an angioplasty. The nurse reinforces instructions to the client regarding the procedure and home care measures. Which statement by the client indicates an understanding of the instructions?

• A. I am considering cutting my workload.
• B. I need to cut down on cigarette smoking.
• C. I am so relieved that my heart is repaired.
• D. I need to adhere to my dietary restrictions.

Correct answer: B

Rationale: The correct answer is B because cutting down on cigarette smoking is crucial for improving heart health after angioplasty. Smoking cessation helps in reducing the risk of complications and promotes better outcomes. Choices A and C are not directly related to post-angioplasty care. While reducing workload may be beneficial, it is not specifically related to the client's cardiac health. Feeling relieved that the heart is repaired is a positive emotional response but does not reflect understanding of the necessary measures. Adhering to dietary restrictions is important, but in this scenario, smoking cessation takes higher priority due to its immediate impact on heart health.

2. The LPN/LVN is assisting in the care of a client with chronic heart failure who is receiving digoxin (Lanoxin). Which sign should the nurse monitor for that could indicate digoxin toxicity?

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

Correct answer: A

Rationale: Bradycardia is a common sign of digoxin toxicity and should be closely monitored. Digoxin toxicity can lead to various cardiac dysrhythmias, with bradycardia being a significant indicator. Monitoring the client's heart rate is crucial to detect and manage digoxin toxicity promptly. Tachycardia, hypertension, and hyperglycemia are not typically associated with digoxin toxicity. Tachycardia is more commonly seen with inadequate treatment of heart failure, hypertension is a possible but less common effect, and hyperglycemia is not a typical sign of digoxin toxicity.

3. The nurse is preparing to administer an intravenous dose of furosemide (Lasix) to a client with heart failure. The nurse should monitor for which potential side effect?

• A. Hypertension
• B. Hyperkalemia
• C. Hypokalemia
• D. Hypoglycemia

Correct answer: C

Rationale: Furosemide is a loop diuretic that works by promoting the excretion of water and electrolytes, including potassium. This loss of potassium can lead to hypokalemia, which can be a potential side effect of furosemide administration. Hypokalemia can result in cardiac dysrhythmias and other complications, especially in clients with heart failure who may already have compromised cardiac function. Therefore, monitoring for signs of hypokalemia, such as muscle weakness, cardiac irregularities, and fatigue, is essential when administering furosemide. Choice A, hypertension, is incorrect because furosemide is actually used to treat hypertension by reducing excess fluid in the body. Choice B, hyperkalemia, is incorrect as furosemide causes potassium loss, leading to hypokalemia. Choice D, hypoglycemia, is unrelated to the mechanism of action of furosemide and is not a common side effect associated with its administration.

4. A client with hypertension is prescribed a thiazide diuretic. What instruction should the nurse reinforce to the client?

• A. Take the medication in the morning.
• B. Increase potassium intake in the diet.
• C. Weigh yourself daily.
• D. Limit fluid intake to 2 liters per day.

Correct answer: C

Rationale: The correct answer is to weigh oneself daily. This instruction is important as daily weights help monitor fluid loss and are crucial for detecting early signs of fluid imbalance when taking a diuretic. Weighing daily allows for timely adjustments in treatment and helps prevent complications associated with fluid imbalance. Choice A is not directly related to the client's need for monitoring fluid balance. Choice B, although important for some diuretics, is not specific to thiazide diuretics. Choice D is not appropriate as limiting fluid intake without proper monitoring can lead to dehydration, especially when taking diuretics.

5. The client with Raynaud's phenomenon is being taught by the nurse about preventing episodes. Which instruction should the nurse reinforce?

• A. Wear gloves in cold weather.
• B. Avoid caffeine and chocolate.
• C. Increase intake of vitamin C.
• D. Use a heating pad for warmth.

Correct answer: A

Rationale: The correct answer is A: 'Wear gloves in cold weather.' Wearing gloves in cold weather is essential for preventing vasoconstriction and subsequent episodes of Raynaud's phenomenon. Cold temperatures can trigger vasospasms in individuals with Raynaud's, and wearing gloves helps maintain warmth and prevent the constriction of blood vessels in the extremities, reducing the likelihood of an episode. Choices B, C, and D are incorrect because while avoiding caffeine and chocolate, increasing vitamin C intake, and using a heating pad for warmth can be beneficial for overall health, they are not specifically targeted at preventing Raynaud's phenomenon episodes triggered by cold weather.

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