Nursing Elites

1. The client is being ambulated due to activity intolerance caused by bacterial endocarditis. How can the nurse determine that the client is best tolerating ambulation?

• A. Mild dyspnea after walking 10 feet
• B. Minimal chest pain rated 1 on a 1-to-10 pain scale
• C. Pulse rate that increases from 68 to 94 beats per minute
• D. Blood pressure that increases from 114/82 to 118/86 mm Hg

Correct answer: D

Rationale: A slight increase in blood pressure without significant symptoms indicates that the client is tolerating the activity. In this scenario, a mild increase in blood pressure without other symptoms is a positive sign of tolerance to ambulation despite the underlying condition of bacterial endocarditis. Choices A, B, and C are not the best indicators of tolerance to ambulation in this case. Mild dyspnea after walking a short distance, minimal chest pain, and an increase in pulse rate are common signs that the activity might not be well-tolerated by the client with a history of bacterial endocarditis.

2. A client with a history of heart failure is being discharged with a prescription for digoxin (Lanoxin). The nurse should include which instruction in the discharge teaching?

• A. Take your pulse before each dose and hold the medication if your pulse is below 60 beats per minute.
• B. Increase your fluid intake to at least 3 liters per day.
• C. Report any weight loss of more than 2 pounds in a week.
• D. Take the medication with meals to avoid gastrointestinal upset.

Correct answer: A

Rationale: The correct instruction for discharge teaching regarding digoxin (Lanoxin) is to advise the client to take their pulse before each dose and to hold the medication if their pulse is below 60 beats per minute. Digoxin can cause bradycardia, so monitoring the pulse is crucial to prevent potential complications. Choice B is incorrect because excessive fluid intake can lead to fluid overload, worsening heart failure. Choice C is not directly related to digoxin therapy. Choice D is inaccurate as digoxin is usually taken on an empty stomach to facilitate absorption.

3. A client is receiving intravenous heparin therapy for the treatment of deep vein thrombosis (DVT). Which laboratory test result should the LPN/LVN monitor to ensure the client is receiving a therapeutic dose?

• A. Prothrombin time (PT)
• B. Activated partial thromboplastin time (aPTT)
• C. International normalized ratio (INR)
• D. Platelet count

Correct answer: B

Rationale: The correct laboratory test result that the LPN/LVN should monitor to ensure the client is receiving a therapeutic dose of heparin therapy is the activated partial thromboplastin time (aPTT). The aPTT test is specifically used to monitor heparin therapy, ensuring that the dose administered is within the therapeutic range. Monitoring aPTT helps to prevent complications such as bleeding or clot formation by maintaining the appropriate anticoagulant effect of heparin. Prothrombin time (PT) and International normalized ratio (INR) are more commonly used to monitor warfarin therapy, not heparin. Platelet count is not a direct indicator of heparin's therapeutic effect and is not used to monitor heparin therapy.

4. A client has a new prescription for atenolol. Which of the following instructions should be included?

• A. Take the medication with food.
• B. Monitor heart rate daily.
• C. Avoid eating foods high in potassium.
• D. Take the medication at bedtime.

Correct answer: B

Rationale: The correct answer is to monitor heart rate daily. Atenolol is a beta-blocker that can lead to bradycardia, a condition characterized by a slow heart rate. Monitoring the heart rate daily is essential to detect any abnormal changes promptly, allowing for timely medical intervention if necessary. Choice A is incorrect because atenolol can be taken with or without food. Choice C is irrelevant as atenolol does not interact with potassium-rich foods. Choice D is incorrect as atenolol is usually taken in the morning to help manage blood pressure throughout the day.

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

• A. Monitor your heart rate daily.
• B. Take the medication at bedtime.
• C. Avoid consuming grapefruit juice.
• D. Take the medication with food.

Correct answer: A

Rationale: The correct answer is to instruct the client to monitor their heart rate daily when taking verapamil. Verapamil is a calcium channel blocker that can cause bradycardia, making it crucial to monitor the heart rate regularly to detect any changes promptly. Choice B, taking the medication at bedtime, is not specifically related to verapamil administration. Choice C, avoiding grapefruit juice, is more relevant to medications metabolized by CYP3A4 enzymes, not verapamil. Choice D, taking the medication with food, is not a specific instruction for verapamil, as it can be taken with or without food.

Similar Questions