Nursing Elites

1. A client is receiving digoxin (Lanoxin) 0.25 mg daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider?

• A. Blood pressure 94/60 mm Hg
• B. Heart rate 76 bpm
• C. Urine output 50 ml/hour
• D. Respiratory rate 16 bpm

Correct answer: A

Rationale: The correct answer is 'Blood pressure 94/60 mm Hg.' Both digoxin and metoprolol decrease the heart rate. Metoprolol specifically affects blood pressure. Therefore, the heart rate and blood pressure need to be within normal range (HR 60-100 bpm; systolic BP above 100 mm Hg) to safely administer both medications. A blood pressure of 94/60 mm Hg indicates hypotension, which could be exacerbated by metoprolol, necessitating immediate reporting to the healthcare provider. Choices B, C, and D are within normal limits and do not pose immediate risks related to the administration of these medications.

2. The clinic nurse is assessing jaundice in a child with hepatitis. Which anatomical area would provide the best data regarding the presence of jaundice?

• A. The nail beds.
• B. The skin in the sacral area.
• C. The skin in the abdominal area.
• D. The membranes in the ear canal.

Correct answer: A

Rationale: Jaundice, if present, can be best assessed in areas such as the sclera, nail beds, and mucous membranes due to the yellowing of these tissues. The nail beds specifically provide a good indication of jaundice. The skin in the sacral area (Option B) is not typically the best area for assessing jaundice as it is less visible and not as reliable as the nail beds. The skin in the abdominal area (Option C) may show generalized jaundice, but the nail beds are more specific for detecting early signs. Lastly, assessing the membranes in the ear canal (Option D) is not a standard method for evaluating jaundice; the sclera and nail beds are more commonly used for this purpose.

3. A patient asks the nurse why they must have a heparin injection. What is the nurse's best response?

• A. Heparin will dissolve clots that you have.
• B. Heparin will reduce the platelets that make your blood clot.
• C. Heparin will work better than warfarin.
• D. Heparin will prevent new clots from developing.

Correct answer: D

Rationale: The correct answer is D: 'Heparin will prevent new clots from developing.' Heparin is an anticoagulant medication that helps prevent the formation of new blood clots. It does not dissolve existing clots (choice A), reduce platelets (choice B), or necessarily work 'better' than warfarin (choice C) but rather functions differently. The primary action of heparin is to prevent the development of new clots, especially in conditions where clot formation is a concern.

4. A nurse is caring for an infant who has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present?

• A. Slow pulse rate
• B. Weight gain
• C. Decreased systolic pressure
• D. Irregular WBC lab values

Correct answer: B

Rationale: Weight gain due to fluid accumulation is associated with heart failure and congenital heart defects. When the heart is unable to circulate blood normally, the kidneys receive less blood, leading to reduced fluid filtration into the urine. The excess fluid accumulates in various body parts such as the lungs, liver, eyes, and sometimes in the legs. Slow pulse rate (Choice A) is less likely as infants with heart failure typically present with tachycardia due to the body compensating for decreased cardiac output. Decreased systolic pressure (Choice C) is also less likely as heart failure typically leads to increased blood pressure as the body tries to maintain adequate perfusion. Irregular white blood cell (WBC) values (Choice D) are not directly associated with congenital heart defects unless there is an underlying infection or inflammatory process.

5. The nurse has provided dietary instructions to the mother of a child with celiac disease. The nurse determines that further instruction is needed if the mother states that she will include which food item in the child's nutritional plan?

• A. Corn
• B. Chicken
• C. Oatmeal
• D. Vitamin supplements

Correct answer: C

Rationale: In celiac disease, individuals need to avoid gluten-containing foods like wheat, rye, barley, and oats. Oatmeal contains gluten unless it is specifically labeled as gluten-free. Corn and rice are safe alternatives for individuals with celiac disease as they do not contain gluten. Chicken is a naturally gluten-free protein source. While vitamin supplements may be necessary to address deficiencies due to malabsorption, oatmeal poses a risk of gluten exposure, making it an incorrect choice for a child with celiac disease.

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