Nursing Elites

1. The nurse is providing discharge teaching to a client who has a new prescription for digoxin (Lanoxin). Which statement by the client indicates a need for further teaching?

• A. I will take my pulse before taking the medication.
• B. I will take the medication at the same time every day.
• C. I should avoid taking antacids at the same time as this medication.
• D. I should eat foods high in potassium while taking this medication.

Correct answer: D

Rationale: The correct answer is D. Clients taking digoxin should avoid eating foods high in potassium, as this can affect the medication's efficacy. Choices A, B, and C are correct statements regarding digoxin administration and precautions, indicating the client's understanding of the medication and its management.

2. The client is receiving discharge instructions for a new antihypertensive medication. Which statement by the client indicates a need for further teaching?

• A. I will stop taking the medication if I experience dizziness.
• B. I will monitor my blood pressure regularly.
• C. I will avoid drinking alcohol while taking this medication.
• D. I will rise slowly from a sitting to a standing position.

Correct answer: A

Rationale: The correct answer is A. Stopping antihypertensive medication abruptly can lead to rebound hypertension, which can be dangerous. Clients should never discontinue their medication without consulting their healthcare provider first. Choice B is correct because monitoring blood pressure is essential when taking antihypertensive medication to ensure it stays within the target range. Choice C is correct as alcohol can potentiate the hypotensive effects of antihypertensive medications. Choice D is correct as orthostatic hypotension can occur, so rising slowly helps prevent dizziness and falls. Therefore, choice A is the statement that indicates a need for further teaching.

3. A female client with chronic back pain has been taking muscle relaxants and analgesics to manage the discomfort, but is now experiencing an acute episode of pain that is not relieved by this medication regime. The client tells the nurse that she does not want to have back surgery for a herniated intervertebral disk, and reports that she has found acupuncture effective in resolving past acute episodes. Which response is best for the nurse to provide?

• A. Surgery removes the disk and is the only treatment that can totally resolve the pain
• B. The medication regimen you previously used should be re-evaluated for dose adjustment
• C. Massage and hot pack treatments are less invasive and can provide temporary relief
• D. Acupuncture is a complementary therapy that is often effective for management of pain

Correct answer: D

Rationale: Acupuncture has been effective for the client previously, supporting continued use.

4. An 80-year-old client admitted with a diagnosis of a possible cerebral vascular accident has had a blood pressure ranging from 180/110 to 160/100 over the past 2 hours. The nurse has also noted increased lethargy. Which assessment finding should the nurse report immediately to the healthcare provider?

• A. Slurred speech
• B. Incontinence
• C. Muscle weakness
• D. Rapid pulse

Correct answer: A

Rationale: Slurred speech is a classic sign of a worsening stroke, suggesting a potential blockage or hemorrhage affecting speech centers in the brain. Prompt reporting of this symptom to the healthcare provider is crucial for immediate evaluation and intervention. While incontinence (Choice B) is important to monitor, it is not considered an immediate priority over slurred speech in this context. Muscle weakness (Choice C) and rapid pulse (Choice D) are also relevant in stroke assessment, but slurred speech takes precedence due to its strong association with neurological deficits in the setting of a possible cerebral vascular accident.

5. When performing nasotracheal suctioning on a client with a respiratory infection, what technique should be used?

• A. Apply intermittent suction when withdrawing the catheter.
• B. Apply continuous suction during insertion of the catheter.
• C. Apply suction only during insertion of the catheter.
• D. Insert the catheter while the client is exhaling.

Correct answer: A

Rationale: The correct technique for nasotracheal suctioning is to apply intermittent suction when withdrawing the catheter. This method helps prevent damage to the mucosa and is the recommended approach. Continuous suction during insertion (choice B) can cause trauma to the airway lining. Applying suction only during insertion (choice C) is not sufficient for effective removal of secretions. Inserting the catheter while the client is exhaling (choice D) does not follow the standard procedure for nasotracheal suctioning.

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