Nursing Elites

1. The client with heart failure is prescribed furosemide (Lasix). Which electrolyte imbalance is the nurse most likely to monitor for?

• A. Hyperkalemia
• B. Hypernatremia
• C. Hypokalemia
• D. Hyponatremia

Correct answer: C

Rationale: The correct answer is C: Hypokalemia. Furosemide, a loop diuretic, commonly causes potassium loss, leading to hypokalemia. The nurse should closely monitor for decreased potassium levels in a client receiving furosemide to prevent complications such as cardiac arrhythmias or muscle weakness. Hyperkalemia (Choice A) is not typically associated with furosemide use. Hypernatremia (Choice B) refers to high sodium levels and is not the primary concern with furosemide. Hyponatremia (Choice D) is low sodium levels, which can occur but is less common than hypokalemia in clients taking furosemide.

2. The client has been prescribed warfarin (Coumadin) and is being educated about dietary restrictions. Which food should the client be advised to avoid or eat in consistent amounts?

• A. Bananas
• B. Spinach
• C. Oranges
• D. Yogurt

Correct answer: B

Rationale: Spinach is high in vitamin K, which can interfere with the effectiveness of warfarin. It is important for clients taking warfarin to maintain consistent levels of vitamin K intake to ensure the medication works properly. Foods rich in vitamin K, such as spinach, can counteract the effects of warfarin, leading to potential complications. Therefore, clients on warfarin are advised to either avoid or consume vitamin K-rich foods, like spinach, in consistent amounts to maintain the medication's efficacy. Bananas, oranges, and yogurt are not high in vitamin K and do not significantly impact the effectiveness of warfarin, making them safe options for clients taking this medication.

3. The LPN/LVN is assisting in the care of a client with chronic heart failure who is receiving furosemide (Lasix). Which instruction should the nurse reinforce with the client?

• A. Limit your fluid intake to avoid fluid overload.
• B. Increase your potassium intake by eating bananas and oranges.
• C. Weigh yourself once a week to monitor for fluid retention.
• D. Take the medication at night to avoid frequent urination during the day.

Correct answer: B

Rationale: The correct instruction for the nurse to reinforce with the client is to increase potassium intake by eating bananas and oranges. Furosemide can lead to potassium loss, potentially causing hypokalemia. By increasing potassium intake through diet, the client can help prevent this electrolyte imbalance and maintain overall health. Choices A, C, and D are incorrect. Limiting fluid intake is not the appropriate instruction, as furosemide is a diuretic that already helps in fluid management. Weighing once a week is not as crucial as monitoring potassium levels, and taking the medication at night does not impact potassium levels.

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

• A. Take the medication in the morning.
• B. Avoid consuming grapefruit juice.
• C. Take the medication with a full glass of water.
• D. Monitor for signs of weight gain.

Correct answer: B

Rationale: The correct instruction for the nurse to include is to 'Avoid consuming grapefruit juice.' Grapefruit juice can increase sertraline levels, leading to an elevated risk of side effects. Instructing the client to avoid grapefruit juice is crucial to prevent potential interactions that could impact the effectiveness and safety of the medication. The other options are not directly related to sertraline administration. Taking the medication in the morning may vary depending on individual preferences or the prescriber's directions. Taking the medication with a full glass of water is a general instruction for many medications and not specific to sertraline. Monitoring for signs of weight gain is important but not a direct instruction related to taking sertraline.

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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