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. The healthcare provider is preparing to administer a calcium channel blocker to a client with hypertension. What parameter should be checked before administering the medication?

• A. Apical pulse
• B. Serum calcium level
• C. Blood pressure
• D. Respiratory rate

Correct answer: C

Rationale: Before administering a calcium channel blocker to a client with hypertension, the healthcare provider should check the client's blood pressure. Calcium channel blockers are used to lower blood pressure, making it essential to assess the current blood pressure to ensure it is within the appropriate range for administration. Checking the apical pulse (choice A) is not the priority before administering a calcium channel blocker, as the focus should be on blood pressure. Serum calcium level (choice B) is not directly related to the administration of calcium channel blockers for hypertension. Respiratory rate (choice D) is not the primary parameter to check before administering a calcium channel blocker in this scenario.

3. 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.

4. The LPN/LVN is assisting with the care of a client who has been diagnosed with a myocardial infarction (MI). Which laboratory test result would the nurse expect to see elevated within the first 24 hours of the client's admission?

• A. Serum troponin
• B. Serum creatinine
• C. Serum sodium
• D. Serum albumin

Correct answer: A

Rationale: Elevated serum troponin levels are indicative of myocardial damage and are commonly used as a diagnostic marker for myocardial infarction. Troponin levels typically rise within a few hours of an MI and remain elevated for several days, making it a crucial test for early detection and monitoring of cardiac injury. Serum creatinine is not typically elevated in the acute phase of a myocardial infarction. Serum sodium and serum albumin levels are not directly associated with myocardial infarction and are unlikely to be elevated in the first 24 hours following an MI.

5. A client with chronic obstructive pulmonary disease (COPD) is prescribed a metered-dose inhaler (MDI) with a spacer. Which instruction should the nurse reinforce to ensure correct use?

• A. Inhale deeply and slowly after activating the MDI.
• B. Hold the breath for 5 seconds after inhaling the medication.
• C. Rinse the mouth immediately after using the MDI.
• D. Exhale fully before placing the mouthpiece in the mouth.

Correct answer: A

Rationale: Inhaling deeply and slowly after activating the MDI is the correct instruction to ensure effective delivery of the medication to the lungs. This technique helps the medication reach the lower airways where it can be most beneficial in managing COPD symptoms. Inhaling too quickly or not deeply enough may result in improper drug delivery and reduce the effectiveness of the treatment. Holding the breath for 5 seconds after inhaling the medication (Choice B) may not be necessary and could cause discomfort without additional benefits. Rinsing the mouth immediately after using the MDI (Choice C) is not necessary unless specified by the healthcare provider. Exhaling fully before placing the mouthpiece in the mouth (Choice D) is not ideal as it may result in inadequate medication delivery to the lungs.

Similar Questions