Nursing Elites

1. A client who is taking clonidine (Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make?

• A. How long has the client been taking the medication?
• B. Assess the client's dietary habits.
• C. Check for signs of infection.
• D. Evaluate the client's sleep pattern.

Correct answer: A

Rationale: The correct answer is A. When a client reports drowsiness while taking clonidine, the nurse should assess how long the client has been taking the medication. Drowsiness is a common side effect that can occur in the early weeks of treatment with clonidine. By understanding the duration of medication use, the nurse can determine if the drowsiness is a temporary effect that may decrease over time. Choices B, C, and D are incorrect because assessing the client's dietary habits, checking for signs of infection, or evaluating the client's sleep pattern would not directly address the drowsiness associated with clonidine use.

2. A first-grade boy is sent to the school nurse after he fainted while playing tag during recess. When he arrives in the clinic he is alert and oriented and his vital signs include temperature of 97.8°F, pulse 96 bpm, respirations 15 breaths/minute, and blood pressure 80/56 mmHg. Which intervention is most important for the nurse to implement?

• A. request transport of the child to his pediatrician's office
• B. call the child's parents and send him home for the day
• C. compare the child's body mass index to normal values
• D. measure the child's pulse and blood pressure every 15 minutes

Correct answer: D

Rationale: In this scenario, the most important intervention for the nurse to implement is to measure the child's pulse and blood pressure every 15 minutes. The child experienced a syncopal episode (fainting) which could be due to various reasons, including dehydration or cardiac issues. Monitoring vital signs frequently will help detect any changes that may indicate underlying health issues. Requesting transport to the pediatrician's office or sending the child home without continuous monitoring may not provide immediate assessment and intervention. Comparing the child's body mass index to normal values is not relevant in addressing the immediate concern of monitoring vital signs after a syncopal episode.

3. The healthcare provider is preparing to administer digoxin (Lanoxin) to a client. Which assessment finding should the healthcare provider report before administering the medication?

• A. Apical pulse of 58 beats per minute.
• B. Serum potassium level of 3.0 mEq/L.
• C. Blood pressure of 140/90 mm Hg.
• D. Client reports seeing halos around lights.

Correct answer: D

Rationale: Seeing halos around lights is a classic symptom of digoxin toxicity, known as visual disturbances. This finding indicates an adverse effect of digoxin and should be reported immediately to the healthcare provider. Monitoring for visual changes is crucial as it can progress to more severe toxicity, leading to life-threatening dysrhythmias or other complications. Apical pulse, serum potassium level, and blood pressure are important assessments when administering digoxin, but the presence of visual disturbances, such as seeing halos around lights, takes precedence due to its direct association with digoxin toxicity. Changes in these other parameters should also be noted and addressed, but they are not the priority when compared to a symptom directly linked to potential toxicity.

4. The nurse is preparing a client for a scheduled surgical procedure. What client statement should the nurse report to the healthcare provider?

• A. I am very anxious about the surgery.
• B. I drank a glass of juice after midnight.
• C. I have an allergy to latex.
• D. I had nausea after my last surgery.

Correct answer: B

Rationale: The correct answer is B. The client's statement of drinking juice after midnight should be reported to the healthcare provider. Consuming liquids after midnight can increase the risk of aspiration during surgery under general anesthesia. Choices A, C, and D are not as critical to report for the client's safety during the surgical procedure. Anxiety about surgery, latex allergy, and postoperative nausea, although important for overall care, do not pose immediate risks during the surgical preparation as the intake of fluids does.

5. When developing a presentation on injury prevention for high school students in a health education class, which topic is most important for the nurse to include?

• A. Sports-related injuries
• B. Substance abuse
• C. Seat belt safety
• D. Pregnancy prevention

Correct answer: C

Rationale: The correct answer is C: Seat belt safety. This topic is crucial as it can significantly reduce the risk of injury or death in car accidents, which is a common cause of severe injuries among high school students. While sports-related injuries, substance abuse, and pregnancy prevention are important topics, seat belt safety directly addresses a preventable cause of injuries that can have immediate life-saving effects.

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