Nursing Elites

1. The nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage does the nurse instruct the client to select from the menu?

• A. Tea
• B. Cola
• C. Coffee
• D. Lemonade

Correct answer: D

Rationale: Lemonade is the correct choice as it is caffeine-free, unlike tea, cola, and coffee, which contain caffeine that can potentially affect the client's heart rhythm. Caffeine can increase heart rate and blood pressure, which may not be advisable for a client with a recent MI. Tea, cola, and coffee should be avoided due to their caffeine content, which can have stimulant effects on the heart and may not be beneficial for a client recovering from a myocardial infarction.

2. What is the initial action the nurse should take for a client who had a myocardial infarction (MI) and is experiencing restlessness, agitation, and an increased respiratory rate?

• A. Administer oxygen.
• B. Administer morphine sulfate.
• C. Notify the healthcare provider.
• D. Take the client's blood pressure.

Correct answer: A

Rationale: Administering oxygen is the priority action for a client experiencing restlessness, agitation, and an increased respiratory rate after a myocardial infarction (MI). This intervention helps ensure adequate oxygenation, improve cardiac function, and reduce the workload on the heart. Oxygen therapy takes precedence over administering medications like morphine sulfate or notifying the healthcare provider as it addresses the immediate need for oxygenation. Checking the blood pressure is also important but not as urgent as ensuring proper oxygen supply.

3. The nurse is caring for a client who has returned to the unit after undergoing a cardiac catheterization. The nurse should monitor for which common complication following this procedure?

• A. Hypertension
• B. Hypotension
• C. Hemorrhage
• D. Hyperglycemia

Correct answer: C

Rationale: Following a cardiac catheterization, a common complication to monitor for is bleeding or hemorrhage at the catheter insertion site. Hemorrhage is a significant concern due to the potential for rapid blood loss, leading to hypovolemic shock and other serious complications. Monitoring for signs of bleeding, such as swelling, hematoma, or drop in hemoglobin levels, is crucial for timely intervention. Hypertension is not a common complication post-cardiac catheterization; instead, hypotension may occur due to vasovagal response or bleeding. Hyperglycemia is not typically associated with cardiac catheterization unless the client has pre-existing diabetes or stress-induced hyperglycemia.

4. Which laboratory test should be monitored to evaluate the effectiveness of anticoagulant therapy in a client with deep vein thrombosis (DVT)?

• A. Complete blood count (CBC)
• B. Activated partial thromboplastin time (aPTT)
• C. Serum electrolytes
• D. Liver function tests

Correct answer: B

Rationale: Activated partial thromboplastin time (aPTT) is the laboratory test monitored to evaluate the effectiveness of anticoagulant therapy, particularly with heparin. It measures the time it takes for blood to clot, and monitoring aPTT helps ensure the therapeutic range is maintained to prevent clot formation and excessive bleeding. Choices A, C, and D are incorrect because a complete blood count (CBC) assesses overall health, serum electrolytes evaluate the body's electrolyte balance, and liver function tests assess liver health, none of which directly evaluate the effectiveness of anticoagulant therapy for DVT.

5. A client has a new prescription for metformin. Which of the following statements should the nurse include in the teaching?

• A. Take the medication with a full glass of water.
• B. Monitor for signs of hypoglycemia.
• C. Increase your fluid intake.
• D. Expect a metallic taste in your mouth.

Correct answer: C

Rationale: Increasing fluid intake is an important teaching point for clients starting metformin to prevent gastrointestinal discomfort, a common side effect of this medication. Metformin can cause gastrointestinal symptoms such as nausea, bloating, and diarrhea, which can be reduced by staying well-hydrated. Therefore, advising the client to increase their fluid intake will help minimize these side effects and improve medication tolerance. The other options are incorrect: Option A is a general instruction for taking medications but not specifically related to metformin. Option B is incorrect because metformin typically does not cause hypoglycemia but rather hyperglycemia. Option D is also incorrect as a metallic taste in the mouth is not a common side effect of metformin.

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