Nursing Elites

1. 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.

2. A client reports chest pain that is unrelieved by three doses of nitroglycerin taken 5 minutes apart. What is the nurse's next best action?

• A. Administer another dose of nitroglycerin.
• B. Call the healthcare provider immediately.
• C. Provide oxygen via nasal cannula.
• D. Place the client in a supine position.

Correct answer: B

Rationale: In the scenario described, the client's chest pain persists despite three doses of nitroglycerin, indicating a potentially severe cardiac issue like a myocardial infarction. The priority for the nurse in this situation is to involve the healthcare provider promptly. Calling the healthcare provider immediately is essential to ensure timely evaluation and appropriate intervention for the client. Administering more nitroglycerin without further assessment or instructions may not be safe and could delay necessary treatments. Providing oxygen or changing the client's position may offer some comfort but does not address the underlying potentially life-threatening condition, making these options less appropriate as the immediate next best action.

3. A client with chronic heart failure has been prescribed furosemide (Lasix). Which instruction should the nurse reinforce to the client regarding this medication?

• A. Take the medication with food.
• B. Limit foods high in potassium while taking this medication.
• C. Report any muscle cramps or weakness to your healthcare provider.
• D. Expect to urinate more frequently while on this medication.

Correct answer: C

Rationale: The correct instruction for the nurse to reinforce to the client regarding furosemide (Lasix) is to report any muscle cramps or weakness to the healthcare provider. Muscle cramps or weakness may indicate hypokalemia, a potential side effect of furosemide. Monitoring and reporting these symptoms promptly can help in preventing complications related to electrolyte imbalances. Choice A is incorrect because furosemide should be taken on an empty stomach. Choice B is not directly related to furosemide use; in fact, foods high in potassium may be beneficial for clients taking furosemide to prevent hypokalemia. Choice D is a common expected side effect of furosemide due to its diuretic action but is not as crucial to report as potential signs of electrolyte imbalances.

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

• A. Avoid consuming dairy products.
• B. Take the medication on an empty stomach.
• C. Increase your intake of folic acid.
• D. Monitor for signs of hyperglycemia.

Correct answer: C

Rationale: Increasing folic acid intake is crucial when taking methotrexate because the medication can lead to folic acid deficiency. Folic acid supplementation helps counteract this deficiency and reduces the risk of adverse effects associated with methotrexate therapy. Choices A, B, and D are incorrect. Avoiding dairy products is not specifically necessary for methotrexate therapy. Methotrexate is usually taken with food to reduce gastrointestinal side effects, so taking it on an empty stomach is not recommended. Monitoring for signs of hyperglycemia is not directly related to methotrexate use.

5. What preoperative instruction should the LPN/LVN reinforce to a client scheduled for a carotid endarterectomy?

• A. You will need to be NPO after midnight before the surgery.
• B. You should avoid deep breathing and coughing after the surgery.
• C. You will be able to eat and drink normally after the procedure.
• D. You can take all of your prescribed medications the morning of surgery.

Correct answer: A

Rationale: The correct preoperative instruction that the LPN/LVN should reinforce to a client scheduled for a carotid endarterectomy is being NPO after midnight before the surgery. This instruction is essential to prevent aspiration and ensure a safe procedure. Avoiding oral intake helps reduce the risk of complications during anesthesia induction and the surgical process. Choices B, C, and D are incorrect because avoiding deep breathing and coughing, resuming normal eating and drinking, and taking all prescribed medications the morning of surgery are not recommended preoperative instructions for a carotid endarterectomy.

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