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

• A. Store the medication in a cool, dry place.
• B. Take the medication as directed by the healthcare provider.
• C. Take the medication 30 minutes before meals.
• D. Take the medication at the first sign of chest pain.

Correct answer: D

Rationale: Instructing the client to take nitroglycerin at the first sign of chest pain is crucial for immediate relief of angina symptoms. Nitroglycerin is a fast-acting medication that helps dilate blood vessels, improving blood flow to the heart muscle. Therefore, prompt administration at the onset of chest pain is essential to alleviate anginal episodes effectively. Choices A, B, and C are incorrect because storing the medication properly, taking it as directed, or before meals are not specific instructions for managing acute anginal episodes, which require immediate action for symptom relief.

3. A client diagnosed with angina pectoris returns to the nursing unit after experiencing an angioplasty. The nurse reinforces instructions to the client regarding the procedure and home care measures. Which statement by the client indicates an understanding of the instructions?

• A. I am considering cutting my workload.
• B. I need to cut down on cigarette smoking.
• C. I am so relieved that my heart is repaired.
• D. I need to adhere to my dietary restrictions.

Correct answer: B

Rationale: The correct answer is B because cutting down on cigarette smoking is crucial for improving heart health after angioplasty. Smoking cessation helps in reducing the risk of complications and promotes better outcomes. Choices A and C are not directly related to post-angioplasty care. While reducing workload may be beneficial, it is not specifically related to the client's cardiac health. Feeling relieved that the heart is repaired is a positive emotional response but does not reflect understanding of the necessary measures. Adhering to dietary restrictions is important, but in this scenario, smoking cessation takes higher priority due to its immediate impact on heart health.

4. A client with a history of myocardial infarction (MI) is being discharged with a prescription for nitroglycerin sublingual tablets. Which instruction should the nurse reinforce?

• A. Store the tablets in a cool, dry place away from light.
• B. Take a tablet every 5 minutes if chest pain occurs.
• C. Place the tablets under the tongue for sublingual absorption.
• D. Take the tablets without water for faster effect.

Correct answer: A

Rationale: The correct answer is A. Nitroglycerin tablets are light and moisture-sensitive, so they should be stored in a cool, dry place away from light to maintain their effectiveness. Option B advises taking a tablet every 5 minutes, which may lead to overdose as this frequency is too high. Option C emphasizes the correct administration route for sublingual tablets. Option D is incorrect as water is not needed for the tablets to take effect.

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

• A. Take the medication with food.
• B. Expect red-orange discoloration of body fluids.
• C. Monitor for signs of hyperglycemia.
• D. Avoid consuming dairy products.

Correct answer: B

Rationale: The correct answer is to inform the client to expect red-orange discoloration of body fluids when taking rifampin. Rifampin is known to cause this side effect, which is harmless but can be surprising to patients. It is important for the nurse to educate the client about this expected change to prevent unnecessary concern or alarm. Monitoring for hyperglycemia is not directly related to rifampin, and taking the medication with food or avoiding dairy products are not specific instructions for this medication.

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