Nursing Elites

1. A client with heart failure is being discharged with a prescription for digoxin (Lanoxin). The nurse should include which instruction in the discharge teaching?

• A. Take your pulse before each dose and hold the medication if your pulse is below 60 beats per minute
• B. Increase your fluid intake to at least 3 liters per day
• C. Report any weight loss of more than 2 pounds in a week
• D. Take the medication with meals to avoid gastrointestinal upset

Correct answer: A

Rationale: The correct instruction for a client taking digoxin is to monitor the pulse before each dose and hold the medication if the pulse is below 60 beats per minute. Digoxin can cause bradycardia, so it is crucial to assess the pulse rate before administration to prevent potential complications. Choices B, C, and D are incorrect because increasing fluid intake, reporting weight loss, or taking the medication with meals are not specific instructions related to the safe use of digoxin.

2. A nurse is assessing a client who is taking hydrocodone. Which of the following findings should the nurse report to the provider?

• A. Constipation
• B. Sedation
• C. Dry mouth
• D. Respiratory depression

Correct answer: D

Rationale: The correct answer is D: Respiratory depression. Hydrocodone is an opioid medication that can cause respiratory depression, a serious side effect that should be reported immediately to the healthcare provider. Constipation, sedation, and dry mouth are common side effects of hydrocodone but are not as concerning as respiratory depression. Constipation can be managed with lifestyle modifications and medications, sedation may improve with time or dosage adjustments, and dry mouth is a common and usually benign side effect.

3. The nurse is planning measures to decrease the incidence of chest pain for a client with angina pectoris. What intervention should the nurse do to effectively accomplish this goal?

• A. Provide a quiet and low-stimulus environment.
• B. Encourage the family to visit very frequently.
• C. Encourage the client to call friends and relatives each day.
• D. Recommend that the client watch TV as a constant diversion.

Correct answer: A

Rationale: The correct answer is A: Provide a quiet and low-stimulus environment. A calm and quiet environment can help reduce stress, which is beneficial in preventing the occurrence of chest pain in clients with angina. Choice B is incorrect because excessive or frequent visitations may lead to increased stress and agitation for the client. Choice C is incorrect as it may not always contribute to a calm environment and could potentially increase the client's stress levels. Choice D is inappropriate as watching TV constantly may not promote a quiet and low-stimulus environment, which is essential in managing angina pectoris.

4. What should be the nurse's priority action when a client diagnosed with angina pectoris complains of chest pain while taking a brisk walk?

• A. Administer nitroglycerin
• B. Have the client sit down
• C. Obtain an electrocardiogram
• D. Apply oxygen

Correct answer: B

Rationale: The nurse's priority action when a client diagnosed with angina pectoris complains of chest pain while taking a brisk walk is to have the client sit down. Sitting down reduces the workload on the heart and may alleviate pain by improving oxygen supply. This action aims to reduce the strain on the heart and improve oxygen delivery to the myocardium, which can help relieve the symptoms of angina pectoris. Administering nitroglycerin could be the next step after having the client sit down if the pain persists. Obtaining an electrocardiogram and applying oxygen are not the immediate priority actions when dealing with angina pectoris symptoms.

5. A client is taking haloperidol. Which of the following findings should the nurse report to the provider?

• A. Weight gain
• B. Dry mouth
• C. Tremors
• D. Tardive dyskinesia

Correct answer: D

Rationale: The correct answer is D: Tardive dyskinesia. Tardive dyskinesia is a serious side effect associated with the long-term use of haloperidol. It is characterized by involuntary movements of the face, tongue, and extremities. Early detection is crucial as tardive dyskinesia may be irreversible and should be reported promptly to the healthcare provider for further evaluation and management. Choices A, B, and C are incorrect because weight gain, dry mouth, and tremors are common side effects of haloperidol but are not as concerning as tardive dyskinesia. While they should still be monitored and managed, tardive dyskinesia requires immediate attention due to its potentially irreversible nature.

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