Nursing Elites

1. The client admitted to the hospital with pulmonary edema is preparing for discharge. The client should be reminded of the importance of complying with which measure to prevent a recurrence?

• A. Weigh oneself every morning before breakfast.
• B. Sleep with the head elevated on multiple pillows.
• C. Adjust diuretic dose without healthcare provider guidance.
• D. Take additional digoxin (Lanoxin) as a preventive measure.

Correct answer: A

Rationale: Monitoring weight daily, especially in the morning before breakfast, is crucial in detecting fluid retention early and preventing pulmonary edema. Sudden weight gain can indicate fluid accumulation, prompting timely intervention to prevent complications. Choice A is the correct answer because daily weight monitoring is a key component in managing heart failure and preventing pulmonary edema recurrence. Choices B and D are not directly related to preventing fluid retention or pulmonary edema recurrence. Choice C is unsafe as adjusting diuretic doses without healthcare provider guidance can lead to electrolyte imbalances and worsening of the condition.

2. The client is receiving digoxin (Lanoxin) for heart failure. Which symptom would indicate digoxin toxicity?

• A. Increased appetite
• B. Yellow or blurred vision
• C. Increased urination
• D. Diarrhea

Correct answer: B

Rationale: Yellow or blurred vision can be a sign of digoxin toxicity. These visual disturbances are concerning as they indicate a potential adverse reaction to the medication. Recognizing this symptom promptly is crucial to prevent serious complications. Increased appetite, increased urination, and diarrhea are not typically associated with digoxin toxicity. Therefore, option B is the correct choice in this scenario.

3. After a client with a history of myocardial infarction (MI) is prescribed aspirin, which instruction should the nurse include in the discharge teaching?

• A. Take the aspirin with food to prevent gastrointestinal upset
• B. Discontinue the aspirin if you experience ringing in your ears
• C. Take the aspirin at bedtime to minimize side effects
• D. Avoid taking aspirin if you are also taking other NSAIDs

Correct answer: A

Rationale: The correct instruction is to take aspirin with food to prevent gastrointestinal upset. Aspirin can irritate the stomach lining, leading to potential gastrointestinal issues. Taking it with food helps reduce this risk by providing a protective layer in the stomach. This is a common recommendation to minimize the risk of gastrointestinal side effects when taking aspirin. Choices B, C, and D are incorrect. Choice B is not a typical reason to discontinue aspirin, as ringing in the ears is not a common side effect of aspirin. Choice C does not have a direct correlation to minimizing side effects of aspirin. Choice D is inaccurate because while caution should be exercised when taking aspirin with other NSAIDs due to the increased risk of bleeding, it does not mean aspirin should be entirely avoided if other NSAIDs are being taken.

4. A client diagnosed with coronary artery disease (CAD) reports chest pain radiating to the left arm. The nurse checks the client's blood pressure and administers nitroglycerin 0.4 mg sublingually. Five minutes later, the client is still experiencing chest pain. What is the next appropriate nursing action?

• A. Administer another dose of nitroglycerin.
• B. Notify the healthcare provider immediately.
• C. Have the client lie down and stay calm.
• D. Give the client aspirin 325 mg to chew.

Correct answer: A

Rationale: If chest pain persists after the first dose of nitroglycerin, it is appropriate to administer a second dose while continuing to monitor the client's response. Nitroglycerin helps dilate blood vessels and improve blood flow to the heart, relieving chest pain associated with coronary artery disease. Reassessing the client's response to a second dose is crucial before considering other interventions like contacting the healthcare provider or providing additional medications. Administering another dose of nitroglycerin aligns with the standard protocol for managing ongoing chest pain in clients with CAD.

5. A client is taking haloperidol. Which of the following findings should the nurse report to the provider?

• A. Weight gain
• B. Dry mouth
• C. Tremors
• D. Tardive dyskinesia

Correct answer: D

Rationale: The correct answer is D: Tardive dyskinesia. Tardive dyskinesia is a serious side effect associated with the long-term use of haloperidol. It is characterized by involuntary movements of the face, tongue, and extremities. Early detection is crucial as tardive dyskinesia may be irreversible and should be reported promptly to the healthcare provider for further evaluation and management. Choices A, B, and C are incorrect because weight gain, dry mouth, and tremors are common side effects of haloperidol but are not as concerning as tardive dyskinesia. While they should still be monitored and managed, tardive dyskinesia requires immediate attention due to its potentially irreversible nature.

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