Nursing Elites

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

• A. I should take my pulse before taking the medication.
• B. I will take my 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. Eating foods high in potassium can lead to hyperkalemia when taken with digoxin, indicating a need for further teaching. Choices A, B, and C are all correct statements that demonstrate understanding of digoxin therapy. Taking the pulse, maintaining a consistent dosing schedule, and avoiding antacids to prevent interactions with digoxin are all appropriate client responses.

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 client is receiving 0.9% sodium chloride IV at 125 mL/hr. The nurse notes that the client has received only 80 mL over the last 2 hr. Which of the following actions should the nurse take first?

• A. Reposition the client
• B. Document the client's IV intake in the medical record
• C. Request a new IV fluid prescription
• D. Check the IV tubing for obstruction

Correct answer: D

Rationale: The correct answer is to check the IV tubing for obstruction. The first step in the nursing process is assessment. By checking the IV tubing for obstruction, the nurse can assess and potentially correct any issues affecting the flow rate. This action may help to ensure that the prescribed infusion rate is maintained. Repositioning the client is not the priority at this stage as the issue seems related to the IV tubing. Documenting the intake or requesting a new prescription are not immediate actions needed to address the current situation with the IV fluid flow.

4. A client with a history of heart failure presents with increased shortness of breath and swelling in the legs. What is the most important assessment for the LPN/LVN to perform?

• A. Monitor the client's oxygen saturation level.
• B. Assess the client's apical pulse.
• C. Check for jugular vein distention.
• D. Measure the client's urine output.

Correct answer: C

Rationale: Checking for jugular vein distention is crucial in assessing fluid overload in clients with heart failure. Jugular vein distention indicates increased central venous pressure, which can be a sign of worsening heart failure. Monitoring oxygen saturation (Choice A) is important but may not provide immediate information on fluid status. Assessing the apical pulse (Choice B) is relevant for monitoring heart rate but may not directly indicate fluid overload. Measuring urine output (Choice D) is essential for assessing renal function and fluid balance but does not provide immediate information on fluid overload in this scenario.

5. A client postoperative expresses pain during dressing changes. What should the nurse prioritize?

• A. Administer pain medication 45 minutes before changing the client’s dressing.
• B. Change the dressing less frequently.
• C. Apply a topical anesthetic before removing the dressing.
• D. Use a non-adherent dressing to reduce pain.

Correct answer: A

Rationale: Administering pain medication before changing the dressing is the priority action as it will help alleviate the client's pain and improve comfort. Choice B, changing the dressing less frequently, may hinder proper wound care and healing. Applying a topical anesthetic (choice C) might offer some relief but systemic pain medication is more effective. Using a non-adherent dressing (choice D) can reduce pain during dressing changes, but addressing immediate pain with medication is the most appropriate intervention in this case.

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