Nursing Elites

1. A patient with heart failure is prescribed digoxin. What is the most important instruction the nurse should provide?

• A. Take an extra dose if you miss one.
• B. Avoid high-potassium foods.
• C. Report any visual disturbances.
• D. Stop taking the medication if your pulse is normal.

Correct answer: C

Rationale: The correct answer is C: 'Report any visual disturbances.' Patients taking digoxin should be instructed to report any visual disturbances, as this can be a sign of digoxin toxicity. Visual disturbances like changes in color vision, blurred vision, or seeing halos around lights can indicate an overdose of digoxin. Choices A, B, and D are incorrect. Instructing a patient to take an extra dose if they miss one can lead to overdose. Avoiding high-potassium foods is important for patients on potassium-sparing diuretics, not digoxin. Stopping the medication if the pulse is normal is incorrect, as the pulse rate alone is not an indicator of digoxin effectiveness or toxicity.

2. A client with a history of peptic ulcer disease is admitted with severe abdominal pain. Which assessment finding should the nurse report to the healthcare provider immediately?

• A. Bowel sounds active in all quadrants.
• B. Blood pressure of 110/70 mm Hg.
• C. Rigid, board-like abdomen.
• D. Heart rate of 90 beats per minute.

Correct answer: C

Rationale: A rigid, board-like abdomen is a sign of peritonitis, a serious complication of peptic ulcer disease that can lead to sepsis and requires immediate intervention. This finding indicates a potential emergency situation that needs urgent medical attention to prevent further complications.

3. What health promotion teaching should prioritize to prevent drug-induced hepatitis?

• A. Finish all prescribed courses of antibiotics, regardless of symptom resolution
• B. Adhere to dosing recommendations of over-the-counter analgesics
• C. Ensure that expired medications are disposed of safely
• D. Ensure that pharmacists regularly review drug regimens for potential interactions

Correct answer: B

Rationale: Adhering to dosing recommendations of over-the-counter analgesics is crucial in preventing drug-induced hepatitis. Overdosing on analgesics can lead to liver damage, making it essential to follow the recommended dosages to reduce the risk of hepatotoxicity.

4. A client with peptic ulcer disease is prescribed ranitidine (Zantac). Which statement by the client indicates the need for further teaching?

• A. I will take this medication at bedtime.
• B. I need to avoid smoking while taking this medication.
• C. I should take this medication with meals.
• D. This medication will help reduce stomach acid.

Correct answer: C

Rationale: The client's statement that they should take ranitidine with meals indicates a need for further teaching. Ranitidine is typically taken at bedtime or before meals to be most effective in reducing stomach acid. Taking it with meals may not provide the optimal therapeutic effect.

5. A client admitted with a diagnosis of sepsis has a central venous pressure (CVP) of 15 mm Hg. What should the nurse do first?

• A. Administer a fluid bolus of 500 ml.
• B. Notify the healthcare provider immediately.
• C. Administer a diuretic.
• D. Continue to monitor the CVP.

Correct answer: B

Rationale: A CVP of 15 mm Hg is higher than normal, indicating possible fluid overload or heart failure, which needs immediate attention. Notifying the healthcare provider is crucial as they can evaluate the client's condition, order appropriate interventions, and prevent potential complications.

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