Nursing Elites

1. Before administering digoxin (Lanoxin) to a client diagnosed with heart failure, the nurse should perform which assessment?

• A. Check the blood pressure.
• B. Obtain an electrocardiogram (ECG).
• C. Assess the apical pulse.
• D. Review the latest electrolyte levels.

Correct answer: C

Rationale: Assessing the apical pulse is crucial before administering digoxin because the medication can lead to bradycardia. Monitoring the apical pulse helps determine the heart rate, and digoxin is typically withheld if the pulse is below 60 beats per minute. This assessment is essential to prevent potential adverse effects associated with digoxin administration. Checking the blood pressure (Choice A) is important but not specific to digoxin administration. Obtaining an electrocardiogram (ECG) (Choice B) may provide valuable information but is not the primary assessment needed before administering digoxin. Reviewing the latest electrolyte levels (Choice D) is important for assessing the overall condition but is not the immediate assessment required before administering digoxin.

2. 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.

3. The client is reinforcing teaching for peripheral artery disease (PAD). Which statement by the client indicates correct understanding?

• A. I will keep my legs elevated on pillows while resting.
• B. I will avoid crossing my legs when sitting.
• C. I will wear tight compression stockings to improve circulation.
• D. I will apply heat to my legs to relieve pain and improve circulation.

Correct answer: B

Rationale: The correct answer is B. Crossing the legs can further impede blood flow in clients with PAD, worsening symptoms. Avoiding leg crossing helps maintain adequate blood flow and reduces the risk of complications associated with peripheral artery disease. Choices A, C, and D are incorrect because elevating the legs, wearing tight compression stockings, and applying heat can exacerbate symptoms in PAD by restricting blood flow or causing potential harm.

4. A client with a diagnosis of myocardial infarction has a new activity prescription allowing the client to have bathroom privileges. As the client stands and begins to walk, the client begins to complain of chest pain. The nurse should take which action?

• A. Assist the client to get back into bed.
• B. Report the chest pain episode to the healthcare provider.
• C. Tell the client to stand still and take the client's blood pressure.
• D. Give a nitroglycerin (Nitrostat) tablet and assist the client to the bathroom.

Correct answer: A

Rationale: In a client with myocardial infarction experiencing chest pain during activity, the priority action is to stop the activity immediately to reduce the heart's workload and oxygen demand. Assisting the client back to bed helps in reducing stress on the heart and can prevent worsening of the condition. Reporting the chest pain episode to the healthcare provider is important but should not delay taking immediate action to alleviate symptoms. Taking the client's blood pressure and administering nitroglycerin are secondary actions after ensuring the client's safety and comfort. Therefore, the correct action is to assist the client back into bed.

5. The healthcare professional is assisting in the care of a client diagnosed with deep vein thrombosis (DVT). Which instruction should be reinforced to prevent complications?

• A. Elevate the affected leg using pillows.
• B. Perform leg exercises while sitting.
• C. Wear snug compression stockings.
• D. Avoid applying ice packs to injuries.

Correct answer: A

Rationale: Elevating the affected leg using pillows is crucial in managing deep vein thrombosis (DVT) as it helps reduce swelling and promote venous return, thereby decreasing the risk of complications such as pulmonary embolism. This position aids in improving blood circulation and preventing blood clots from forming or worsening in the affected leg. Performing leg exercises while sitting might increase the risk of dislodging a blood clot. While snug compression stockings are beneficial, the primary focus should be on elevation. Avoiding ice packs on injuries is unrelated to DVT management.

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