Nursing Elites

1. A client with a diagnosis of myocardial infarction has a new activity prescription allowing the client to have bathroom privileges. As the client stands and begins to walk, the client begins to complain of chest pain. The nurse should take which action?

• A. Assist the client to get back into bed.
• B. Report the chest pain episode to the healthcare provider.
• C. Tell the client to stand still and take the client's blood pressure.
• D. Give a nitroglycerin (Nitrostat) tablet and assist the client to the bathroom.

Correct answer: A

Rationale: In a client with myocardial infarction experiencing chest pain during activity, the priority action is to stop the activity immediately to reduce the heart's workload and oxygen demand. Assisting the client back to bed helps in reducing stress on the heart and can prevent worsening of the condition. Reporting the chest pain episode to the healthcare provider is important but should not delay taking immediate action to alleviate symptoms. Taking the client's blood pressure and administering nitroglycerin are secondary actions after ensuring the client's safety and comfort. Therefore, the correct action is to assist the client back into bed.

2. A client has a new prescription for prednisone. Which of the following statements should the nurse include in the teaching?

• A. You may experience weight gain.
• B. Increase your intake of vitamin K.
• C. Expect increased urinary output.
• D. You may have dark, tarry stools.

Correct answer: A

Rationale: The correct answer is A: 'You may experience weight gain.' Prednisone commonly causes weight gain as a side effect, so it is important for the client to be aware of this potential outcome. Monitoring weight changes can be essential in managing the medication's effects and overall health. Choices B, C, and D are incorrect. Increasing vitamin K intake is not specifically related to prednisone use. Expecting increased urinary output is not a common side effect of prednisone. Dark, tarry stools are more commonly associated with gastrointestinal bleeding rather than prednisone use.

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

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

Correct answer: A

Rationale: The correct answer is to instruct the client to monitor their blood pressure daily. Lisinopril is known to cause hypotension, so monitoring blood pressure regularly is essential to detect any potential issues early on. Choice B is incorrect as lisinopril is usually taken on an empty stomach. Choice C is incorrect as lisinopril can increase potassium levels, so additional intake of potassium-rich foods may lead to hyperkalemia. Choice D is incorrect because grapefruit juice can interact with lisinopril, leading to adverse effects.

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

• A. Take the medication in the morning.
• B. Avoid consuming grapefruit juice.
• C. Take the medication with a full glass of water.
• D. Monitor for signs of weight gain.

Correct answer: C

Rationale: When a client is prescribed amitriptyline, it is important to instruct them to take the medication with a full glass of water. This instruction helps prevent esophageal irritation, as amitriptyline can be harsh on the esophagus. Option C is the correct choice. Option A, taking the medication in the morning, is not specific to amitriptyline and can vary depending on the individual's condition. Option B, avoiding grapefruit juice, is a general precaution for many medications but not specifically related to amitriptyline. Option D, monitoring for signs of weight gain, is not a direct instruction for taking the medication itself and may not be a common side effect of amitriptyline.

5. The client is starting therapy with digoxin (Lanoxin). What instruction should the nurse reinforce about the medication?

• A. Take the medication with meals.
• B. Avoid dairy products.
• C. Monitor for yellow or blurred vision.
• D. Increase potassium-rich foods in the diet.

Correct answer: C

Rationale: The correct answer is C: 'Monitor for yellow or blurred vision.' When a client is taking digoxin, it is crucial to monitor for signs of toxicity, such as yellow or blurred vision, as these can indicate an adverse reaction. Reporting these visual disturbances promptly to the healthcare provider is important for further evaluation and management to prevent potential complications. Choices A, B, and D are incorrect because taking digoxin with meals, avoiding dairy products, or increasing potassium-rich foods are not specific instructions related to monitoring for adverse effects of digoxin therapy.

Similar Questions