Nursing Elites

1. A client with a history of hypertension is being discharged on a low-sodium diet. Which statement by the client indicates a need for further teaching?

• A. I will use fresh herbs and spices instead of salt.
• B. I will avoid canned soups and processed foods.
• C. I can eat as much bacon and sausage as I want because they taste good.
• D. I will read food labels to check for sodium content.

Correct answer: C

Rationale: Choice C is the correct answer because bacon and sausage are high in sodium, which contradicts the low-sodium diet requirement. Consuming them freely would contribute to increased sodium intake, which is not suitable for managing hypertension. Choices A, B, and D demonstrate appropriate understanding and actions for a low-sodium diet, such as using alternatives to salt, avoiding processed foods, and checking food labels for sodium content.

2. A client with heart failure is prescribed an angiotensin-converting enzyme (ACE) inhibitor. The nurse should reinforce which instruction?

• A. Take the medication at bedtime.
• B. Report a persistent dry cough.
• C. Increase potassium-rich foods in the diet.
• D. Avoid taking the medication with meals.

Correct answer: B

Rationale: The correct answer is to instruct the client to report a persistent dry cough. ACE inhibitors can cause a common side effect of a persistent dry cough, which should be promptly reported to the healthcare provider for further evaluation and possible medication adjustment. Option A is incorrect because the timing of ACE inhibitor administration is usually not specified to be at bedtime. Option C is incorrect as increasing potassium-rich foods can lead to hyperkalemia when taking ACE inhibitors. Option D is incorrect because ACE inhibitors can be taken with or without food.

3. A healthcare professional is assessing a client who has been taking isoniazid to treat tuberculosis. The healthcare professional should monitor the client for which of the following findings as an adverse effect of the medication?

• A. Diarrhea
• B. Blurred vision
• C. Hearing loss
• D. Jaundice

Correct answer: D

Rationale: Correct. Jaundice is a serious adverse effect of isoniazid due to liver damage. It is essential to monitor for signs of liver toxicity, such as jaundice, while the client is on this medication. Diarrhea is a common side effect of isoniazid, but it is not as serious as liver damage. Blurred vision and hearing loss are not typically associated with isoniazid use.

4. The client will wear a Holter monitor for continuous cardiac monitoring over the next 24 hours. What action should the nurse take to assist the client?

• A. Shave the front of the client's chest
• B. Give the client a device holder to wear around the waist
• C. Teach the client to rest as much as possible during the next 24 hours
• D. Tell the client to cover the monitor in plastic wrap before taking a bath

Correct answer: B

Rationale: Providing the client with a device holder to wear around the waist allows them to comfortably carry the Holter monitor while engaging in normal activities throughout the 24-hour monitoring period. This approach supports the client's mobility and ensures the monitor is securely in place for accurate readings. Shaving the front of the client's chest is unnecessary and not a standard practice for Holter monitor placement. Instructing the client to rest as much as possible does not promote normal daily activities which are important for accurate monitoring. Covering the monitor in plastic wrap before bathing is not recommended as it may affect the functionality of the device.

5. The client with heart failure is receiving digoxin (Lanoxin). The nurse should monitor the client for which sign of digoxin toxicity?

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

Correct answer: B

Rationale: Bradycardia is a common sign of digoxin toxicity. Digoxin can cause disturbances in the heart's electrical conduction system, leading to a slower heart rate. Therefore, the nurse should closely monitor the client's heart rate for signs of bradycardia, which could indicate digoxin toxicity. Hypertension (Choice A), hyperglycemia (Choice C), and insomnia (Choice D) are not typically associated with digoxin toxicity. Therefore, they are incorrect choices for this question.

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