Nursing Elites

1. A client has a new prescription for digoxin. Which of the following instructions should the nurse include during discharge teaching?

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

Correct answer: B

Rationale: The correct answer is B: 'Monitor heart rate daily.' When a client is prescribed digoxin, it is essential to monitor heart rate daily because digoxin can cause bradycardia, a condition characterized by a slow heart rate. Monitoring the heart rate regularly allows the client to promptly identify any signs of bradycardia and seek medical attention if needed. Choices A, C, and D are incorrect because taking digoxin with food, avoiding grapefruit juice, and increasing potassium-rich foods are not specific instructions related to managing the side effects or monitoring parameters of digoxin therapy.

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

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

Correct answer: B

Rationale: The correct answer is B: 'Monitor blood pressure daily.' When a client is prescribed amlodipine, it is essential to monitor their blood pressure regularly. Amlodipine is known to cause hypotension, so monitoring blood pressure helps ensure it stays within the desired range to prevent complications associated with low blood pressure. Choice A is incorrect because amlodipine can be taken with or without food. Choice C is incorrect as increasing potassium intake is not a specific instruction related to amlodipine. Choice D is incorrect as grapefruit juice interactions are not typically a concern with amlodipine.

3. The LPN/LVN is assisting in the care of a client who has been prescribed enoxaparin (Lovenox) for the prevention of deep vein thrombosis (DVT). Which instruction should the nurse reinforce with the client?

• A. Avoid consuming foods high in vitamin K while taking this medication.
• B. Administer the injection in the same site each time for consistency.
• C. Report any unusual bleeding or bruising to your healthcare provider.
• D. Do not take aspirin if you experience any mild pain or discomfort.

Correct answer: C

Rationale: The correct instruction for the nurse to reinforce with the client is to report any unusual bleeding or bruising to their healthcare provider. This is crucial because unusual bleeding or bruising may indicate excessive anticoagulation, a potential side effect of enoxaparin. Prompt reporting to a healthcare provider is necessary to prevent complications. Choices A, B, and D are incorrect. Choice A is not directly related to enoxaparin and vitamin K interactions. Choice B is incorrect as rotating injection sites is essential for preventing tissue damage and irritation. Choice D is also incorrect as aspirin can increase the risk of bleeding when taken with enoxaparin.

4. A client with a history of angina pectoris reports chest pain while ambulating in the corridor. What should the nurse do first?

• A. Check the client's vital signs.
• B. Assist the client to sit or lie down.
• C. Administer sublingual nitroglycerin.
• D. Apply nasal oxygen at a rate of 2 L/min.

Correct answer: B

Rationale: When a client with a history of angina pectoris experiences chest pain while ambulating, the priority action for the nurse is to assist the client to sit or lie down. This helps reduce the demand on the heart by decreasing physical exertion. Checking vital signs, administering medication, or applying oxygen can follow once the client is in a more comfortable position. Checking vital signs (Choice A) may be important but addressing the immediate discomfort by positioning the client comfortably takes precedence. Administering sublingual nitroglycerin (Choice C) is appropriate but should come after ensuring the client's comfort. Applying nasal oxygen (Choice D) can be beneficial, but it should not be the first action; assisting the client to sit or lie down is the initial priority.

5. The client with diabetes mellitus has gangrene of the toes to the midfoot. Which goal should be included in this client's plan of care?

• A. Restore skin integrity.
• B. Prevent infection.
• C. Promote healing.
• D. Improve nutrition.

Correct answer: B

Rationale: Preventing infection is crucial in clients with gangrene to halt the spread of infection and avert further complications. Infections can exacerbate tissue damage and lead to systemic complications, making infection prevention a priority in the care plan for this client. Restoring skin integrity and promoting healing may not be achievable goals until the infection is under control. Improving nutrition is important for overall health but may not be the priority when the immediate concern is preventing infection.

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