Nursing Elites

1. The nurse prepares to administer digoxin (Lanoxin) to a newborn with a diagnosis of heart failure and notes that the apical rate is 140 beats per minute. Which nursing action is appropriate?

• A. Hold the medication
• B. Administer the digoxin
• C. Notify the healthcare provider
• D. Recheck the apical rate in 1 hour

Correct answer: B

Rationale: The correct answer is to administer the digoxin. An apical rate of 140 bpm is within the normal range for a newborn. Digoxin is commonly prescribed for heart failure in newborns to help improve cardiac function. Holding the medication or notifying the healthcare provider is not necessary as the heart rate is normal for a newborn. Rechecking the apical rate in 1 hour is not needed since the heart rate is within the expected range.

2. The nurse supervises care of a client in Buck’s traction. The nurse determines that care is appropriate if which of the following is observed? (Select all that apply)

• A. The nurse removes the foam boot three times per day to inspect the skin
• B. The staff turn the client to the unaffected side
• C. The staff turn the client to the unaffected side and the nurse asks the client to dorsiflex the foot on the affected leg
• D. The nurse asks the client to dorsiflex the foot on the affected leg

Correct answer: C

Rationale: The correct answer is C. Turning the client to the unaffected side helps prevent complications such as pressure ulcers. Dorsiflexion of the foot on the affected leg helps maintain proper alignment and prevent foot drop. The incorrect choices are A and D. Removing the foam boot multiple times per day can disrupt traction, and asking the client to dorsiflex the foot may not be appropriate without ensuring proper alignment and direction from the healthcare provider.

3. A client is admitted to the hospital with the diagnosis of a right-sided brain attack (CVA). The client is right-handed. Which task will be most difficult for this client?

• A. Eating meals
• B. Writing letters
• C. Combing the hair
• D. Dressing every morning

Correct answer: B

Rationale: The correct answer is B: Writing letters. Writing requires fine motor skills, which are often impaired in a right-handed person with a right-sided CVA. Eating meals (choice A), combing the hair (choice C), and dressing every morning (choice D) involve gross motor skills and may not be as challenging for a right-handed individual with a right-sided CVA compared to the fine motor skill required for writing.

4. In a routine sputum analysis, which of the following indicates proper nursing action before sputum collection?

• A. Secure a clean container
• B. Discard the container if the outside becomes dirty
• C. Rinse the client's mouth with Listerine before collection
• D. Tell the client that 4 tablespoons of sputum are needed

Correct answer: A

Rationale: The correct answer is to secure a clean container before sputum collection. This is essential to prevent contamination of the specimen, ensuring accurate test results and avoiding the introduction of external particles or bacteria. Choice B is incorrect because discarding the container if the outside becomes dirty is not necessary; the cleanliness of the inside is crucial. Choice C is incorrect as rinsing the client's mouth with Listerine before collection may introduce unwanted substances that can affect the test results. Choice D is incorrect as the amount of sputum required can vary depending on the test, and specifying a specific amount without medical guidance is not appropriate.

5. What is the best way to manage a patient's intake of dietary fiber?

• A. Increase intake gradually
• B. Increase intake suddenly
• C. Decrease intake abruptly
• D. Maintain a high intake

Correct answer: A

Rationale: The correct way to manage a patient's intake of dietary fiber is to increase it gradually. This approach helps prevent gastrointestinal discomfort that can occur when fiber intake is suddenly increased. Choice B is incorrect because sudden increases in fiber intake can lead to bloating, gas, and other digestive issues. Choice C is incorrect as decreasing fiber intake abruptly can disrupt bowel regularity and cause constipation. Choice D is incorrect because maintaining a high intake of fiber without considering the patient's current levels can also cause digestive problems.

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