Nursing Elites

1. A client with a diagnosis of 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: D

Rationale: The correct answer is D because adhering to dietary restrictions is crucial in managing heart health post-angioplasty. Choice A focuses on workload, choice B mentions smoking, and choice C reflects relief about heart repair, which are important but do not directly relate to post-angioplasty care instructions.

2. 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.

3. A client has a history of left-sided heart failure. The nurse should look for the presence of which finding to determine whether the problem is currently active?

• A. Presence of ascites
• B. Bilateral lung crackles
• C. Jugular vein distention
• D. Pedal edema bilaterally

Correct answer: B

Rationale: When assessing a client with a history of left-sided heart failure, the presence of bilateral lung crackles is a key finding to determine if the condition is currently active. Crackles in the lungs indicate fluid accumulation, a common sign of left-sided heart failure due to pulmonary congestion. Choices A, C, and D are incorrect because ascites, jugular vein distention, and pedal edema are more commonly associated with right-sided heart failure.

4. The client is receiving furosemide (Lasix) for heart failure. What potential side effect should the nurse monitor for?

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

Correct answer: A

Rationale: The correct answer is A: Hypokalemia. Furosemide, a loop diuretic, causes potassium loss, leading to hypokalemia. Monitoring potassium levels is crucial because hypokalemia can result in cardiac arrhythmias and muscle weakness. Choices B, C, and D are incorrect because furosemide does not typically cause hyperkalemia, hypernatremia, or hypoglycemia.

5. What is the initial action the nurse should take for a client who had a myocardial infarction (MI) and is experiencing restlessness, agitation, and an increased respiratory rate?

• A. Administer oxygen.
• B. Administer morphine sulfate.
• C. Notify the healthcare provider.
• D. Take the client's blood pressure.

Correct answer: A

Rationale: Administering oxygen is the priority action for a client experiencing restlessness, agitation, and an increased respiratory rate after a myocardial infarction (MI). This intervention helps ensure adequate oxygenation, improve cardiac function, and reduce the workload on the heart. Oxygen therapy takes precedence over administering medications like morphine sulfate or notifying the healthcare provider as it addresses the immediate need for oxygenation. Checking the blood pressure is also important but not as urgent as ensuring proper oxygen supply.

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