Nursing Elites

1. A client with heart failure is receiving discharge teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I should weigh myself once a week.
• B. I should limit my fluid intake to 1 liter per day.
• C. I should report a weight gain of 2 pounds in one day.
• D. I should reduce my protein intake to prevent fluid retention.

Correct answer: C

Rationale: The correct answer is C. Reporting a sudden weight gain of 2 pounds in one day is crucial in managing heart failure because it can indicate fluid retention, a common symptom in heart failure. Option A is incorrect as weighing oneself once a week may not provide timely information about fluid retention. Option B is incorrect because fluid intake restriction is individualized and generally involves more specific guidance. Option D is incorrect as protein intake is important but reducing it solely to avoid fluid retention is not the primary focus in heart failure management.

2. A nurse is caring for a client who has left-sided heart failure. Which of the following findings should the nurse expect?

• A. Peripheral edema.
• B. Bradycardia.
• C. Jugular vein distention.
• D. Dependent edema.

Correct answer: C

Rationale: Jugular vein distention is a classic sign of left-sided heart failure due to fluid overload in the pulmonary circulation. This occurs because the heart's left side is unable to pump effectively, causing increased pressure in the pulmonary veins and leading to blood backing up into the pulmonary circulation. Peripheral edema (choice A) and dependent edema (choice D) are more commonly associated with right-sided heart failure where blood pools in the systemic circulation, causing swelling in the extremities. Bradycardia (choice B) is not typically a direct consequence of left-sided heart failure; instead, tachycardia is more commonly seen as the heart compensates for its reduced efficiency.

3. A client with type 2 diabetes mellitus is scheduled for an arteriogram. Which of the following medications should the nurse instruct the client to discontinue 48 hours prior to the procedure?

• A. Atorvastatin
• B. Digoxin
• C. Nifedipine
• D. Metformin

Correct answer: D

Rationale: The correct answer is D, Metformin. Metformin should be discontinued 48 hours before an arteriogram due to the risk of lactic acidosis. Atorvastatin (Choice A) is a statin used to lower cholesterol levels and is not typically contraindicated before an arteriogram. Digoxin (Choice B) is a medication used for heart conditions and does not need to be discontinued before an arteriogram. Nifedipine (Choice C) is a calcium channel blocker used to treat high blood pressure and angina, and it is not necessary to discontinue before the procedure.

4. Which of the following actions is appropriate when administering a blood transfusion?

• A. Verify patient identity
• B. Administer medication
• C. Monitor vital signs
• D. Start blood transfusion without verification

Correct answer: A

Rationale: Verifying the patient's identity is a critical step when administering a blood transfusion to ensure that the correct blood product is given to the right patient. This process helps prevent errors and enhances patient safety. Choice B, 'Administer medication,' is incorrect because the focus during a blood transfusion should be on ensuring the correct blood product is administered. Choice C, 'Monitor vital signs,' is also important but comes after verifying the patient's identity. Choice D, 'Start blood transfusion without verification,' is incorrect and unsafe as patient identification verification is essential prior to starting any medical procedure, especially one as important as a blood transfusion.

5. A nurse is caring for a client who has a new prescription for spironolactone. Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the medication?

• A. Serum sodium.
• B. Serum calcium.
• C. Serum potassium.
• D. Serum glucose.

Correct answer: C

Rationale: Corrected Rationale: Spironolactone is a potassium-sparing diuretic, so serum potassium should be monitored to evaluate its effectiveness. Monitoring serum potassium levels is crucial because spironolactone can cause hyperkalemia as a side effect. Serum sodium, serum calcium, and serum glucose levels are not directly affected by spironolactone and would not provide an accurate assessment of the medication's effectiveness.

Similar Questions