Nursing Elites

1. A client is prescribed digoxin 0.125 mg daily for heart failure. Which of the following client reports should concern the nurse as a sign of digoxin toxicity?

• A. Increased appetite
• B. Visual disturbances
• C. Weight gain
• D. Constipation

Correct answer: B

Rationale: Visual disturbances such as blurred vision or seeing halos around lights are common signs of digoxin toxicity. Increased appetite, weight gain, and constipation are not typically associated with digoxin toxicity. Weight gain could be a sign of worsening heart failure rather than digoxin toxicity. Increased appetite and constipation are not specific signs of digoxin toxicity and are less likely to be related.

2. A nurse is providing care to a client with staphylococcus epidermidis who is prescribed vancomycin. Identify the adverse effect associated with the antibiotic therapy.

• A. Hepatotoxicity
• B. Constipation
• C. Infusion reaction
• D. Immunosuppression

Correct answer: C

Rationale: The correct answer is C: Infusion reaction. Vancomycin can cause infusion reactions like 'Red Man Syndrome,' which involves rashes, flushing, tachycardia, and hypotension. Hepatotoxicity (choice A) is not a common adverse effect of vancomycin. Constipation (choice B) is not typically associated with vancomycin use. Immunosuppression (choice D) is not a direct adverse effect of vancomycin therapy.

3. A healthcare professional is caring for a client receiving gentamicin therapy. Which of the following client assessments is a priority for the healthcare professional to monitor for an adverse effect of this medication?

• A. Urinary output
• B. Serum glucose
• C. Respiratory rate
• D. Hearing acuity

Correct answer: D

Rationale: The correct answer is D: Hearing acuity. Gentamicin is known to be ototoxic, which means it can cause damage to the auditory system leading to hearing loss. Monitoring hearing acuity is crucial to detect early signs of hearing impairment. Monitoring urinary output (choice A) is important for assessing kidney function but is not directly related to gentamicin's adverse effects. Monitoring serum glucose (choice B) and respiratory rate (choice C) are not specifically associated with gentamicin therapy.

4. A nurse is caring for a client receiving patient-controlled analgesia (PCA). Which of the following interventions should the nurse take while caring for this client?

• A. Advise the client to use the pump sparingly to prevent addiction
• B. Encourage the client to use the PCA before dressing changes
• C. Encourage the client's family to administer PCA while the client is sleeping
• D. Increase the client's 4-hour limit as needed

Correct answer: B

Rationale: The correct answer is B because encouraging the client to use the PCA before dressing changes helps in managing pain proactively. Choice A is incorrect as PCA is a safe method of pain control when used appropriately, and the nurse should not suggest using it sparingly. Choice C is incorrect as only the client should operate the PCA to ensure they are in control of their pain management. Choice D is incorrect as changing the PCA limit without proper assessment and orders from the healthcare provider can lead to adverse effects.

5. A nurse is reviewing a client's medication regimen. Which of the following medications places the client at increased risk for digoxin toxicity?

• A. Calcium channel blockers
• B. Potassium-sparing diuretics
• C. Beta blockers
• D. Loop diuretics

Correct answer: D

Rationale: The correct answer is D, Loop diuretics. Loop diuretics can lead to hypokalemia, which increases the risk for digoxin toxicity. Loop diuretics cause potassium loss, and hypokalemia can potentiate the toxic effects of digoxin. Choices A, B, and C are incorrect because calcium channel blockers, potassium-sparing diuretics, and beta blockers do not directly increase the risk of digoxin toxicity.

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