Nursing Elites

1. A nurse is caring for a client who has heart failure and is receiving furosemide. Which of the following findings should the nurse identify as a therapeutic effect of the medication?

• A. Increased shortness of breath.
• B. Weight gain of 2.3 kg (5 lb).
• C. Clear lung sounds.
• D. Bounding pulse.

Correct answer: C

Rationale: The correct answer is C: Clear lung sounds. Clear lung sounds indicate a therapeutic effect of furosemide, as the medication helps reduce fluid overload in heart failure. Choice A, increased shortness of breath, is incorrect as furosemide is used to relieve symptoms like shortness of breath. Choice B, weight gain of 2.3 kg (5 lb), is incorrect as furosemide is a diuretic that helps reduce fluid retention leading to weight loss. Choice D, bounding pulse, is incorrect as furosemide does not directly impact the pulse rate.

2. A nurse is teaching a client who has hypertension about managing blood pressure. Which of the following statements should the nurse make?

• A. Increase your intake of red meat to manage your blood pressure.
• B. You should avoid drinking alcohol while taking this medication.
• C. Exercise for at least 30 minutes most days of the week.
• D. Limit your fluid intake to 3 liters per day.

Correct answer: C

Rationale: The correct statement is C: 'Exercise for at least 30 minutes most days of the week.' Regular exercise is essential in managing blood pressure as it helps improve cardiovascular health. Choice A is incorrect as increasing red meat intake can be detrimental due to its high saturated fat content, which can negatively impact blood pressure. Choice B is not directly related to managing blood pressure unless the medication interacts negatively with alcohol. Choice D, limiting fluid intake to 3 liters per day, is not a general recommendation for managing blood pressure unless specifically advised by a healthcare provider.

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

• A. Take this medication at bedtime to prevent nausea.
• B. Take this medication with a full glass of milk.
• C. Notify your provider if you experience visual disturbances.
• D. Report any muscle pain to your provider.

Correct answer: C

Rationale: The correct answer is C: 'Notify your provider if you experience visual disturbances.' Visual disturbances can indicate digoxin toxicity, so it is essential for clients taking digoxin to report any changes in vision to their healthcare provider. Option A is incorrect because the timing of digoxin administration is crucial, usually in the morning. Option B is inaccurate because digoxin should not be taken with milk as it can affect its absorption. Option D is not directly associated with digoxin use and should not be the priority instruction for a client on this medication.

4. A nurse is caring for a client who has a urinary tract infection (UTI) and is prescribed ciprofloxacin. The nurse should instruct the client to monitor for and report which of the following adverse effects?

• A. Tinnitus.
• B. Photosensitivity.
• C. Urinary frequency.
• D. Insomnia.

Correct answer: B

Rationale: The correct answer is B: Photosensitivity. Ciprofloxacin, an antibiotic commonly used to treat UTIs, can cause photosensitivity as an adverse effect. This reaction makes the skin more sensitive to sunlight, potentially leading to severe sunburns or skin damage. It is crucial for the client to be aware of this adverse effect to take precautions and report any signs of photosensitivity promptly. Choices A, C, and D are incorrect because tinnitus, urinary frequency, and insomnia are not typically associated with ciprofloxacin use. While urinary frequency might be a symptom of UTI, it is not an adverse effect of the medication itself.

5. A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?

• A. Paradoxical pulse
• B. Dependent edema
• C. Pericardial friction rub
• D. Substernal chest pain

Correct answer: A

Rationale: In a client with pericarditis, the priority finding is a paradoxical pulse. This is a crucial sign of cardiac tamponade, a life-threatening complication of pericarditis where fluid accumulates in the pericardial sac, causing compression of the heart. A paradoxical pulse is an exaggerated decrease in systolic blood pressure (>10 mmHg) during inspiration. Prompt recognition and intervention are essential to prevent hemodynamic instability and cardiac arrest. Dependent edema (choice B) is not typically associated with pericarditis. Pericardial friction rub (choice C) is a common finding in pericarditis but does not indicate the urgency of intervention as a paradoxical pulse. Substernal chest pain (choice D) is a classic symptom of pericarditis but is not as critical as a paradoxical pulse in the context of assessing for complications.

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