Nursing Elites

1. A client with a history of atrial fibrillation is taking digoxin (Lanoxin). Which finding should the healthcare provider be notified of immediately?

• A. Heart rate of 52 beats per minute
• B. Blood pressure of 110/70 mmHg
• C. Blood glucose level of 180 mg/dL
• D. Potassium level of 4.0 mEq/L

Correct answer: A

Rationale: A heart rate of 52 beats per minute is a critical finding in a client taking digoxin, as it may indicate digoxin toxicity. Digoxin can cause bradycardia as a side effect, and a heart rate of 52 bpm warrants immediate attention to prevent adverse outcomes. Monitoring and reporting changes in heart rate are crucial in clients on digoxin therapy to prevent serious complications. The other vital signs and laboratory values provided are within normal ranges or not directly associated with digoxin toxicity in this scenario, making them lower priority for immediate reporting.

2. A client has right-sided paralysis following a cerebrovascular accident. Which of the following prescriptions should the nurse anticipate to prevent a plantar flexion contracture of the affected extremity?

• A. Ankle-foot orthotic
• B. Continuous passive motion machine
• C. Abduction splint
• D. Sequential compression device

Correct answer: A

Rationale: An ankle-foot orthotic is the correct choice to prevent a plantar flexion contracture in a paralyzed limb. An ankle-foot orthotic helps maintain proper alignment of the foot and ankle, preventing the foot from being permanently fixed in a pointed-down position. Continuous passive motion machines are typically used to promote joint movement after surgery and would not address the prevention of contractures in this case. Abduction splints are used to keep the legs apart and would not address the specific issue described. Sequential compression devices are used to prevent deep vein thrombosis by promoting circulation in the lower extremities and are not indicated for preventing plantar flexion contractures.

3. A nurse prepares to admit a client who is immediately postoperative to the unit following abdominal surgery. When transferring the client from the gurney to the bed, what should the nurse do?

• A. Lock the wheels on the bed and gurney
• B. Adjust the bed height
• C. Use a slide sheet
• D. Ask for assistance from another nurse

Correct answer: A

Rationale: The correct action for the nurse to take when transferring a postoperative client from the gurney to the bed is to lock the wheels on both the bed and the gurney. Locking the wheels ensures stability and prevents accidents during the transfer. Adjusting the bed height may be necessary for comfort but is not the primary concern during the transfer process. Using a slide sheet may be helpful in repositioning the client once on the bed but is not essential for the initial transfer. Asking for assistance from another nurse is always a good practice, but the immediate action to ensure safety during the transfer is to lock the wheels.

4. A client is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?

• A. Monitor the client for pain in the suprapubic region.
• B. Ensure the client is free of metal objects.
• C. Administer 240 mL (8 oz) of oral contrast before the procedure.
• D. Assist the client with a bowel cleansing.

Correct answer: B

Rationale: The correct action for the nurse to include before an intravenous pyelogram is ensuring the client is free of metal objects. Metal objects can interfere with the imaging procedure and may need to be removed to prevent artifacts. Monitoring for pain in the suprapubic region (choice A) is not directly related to the procedure and is not a standard pre-procedure action. Administering oral contrast (choice C) is more common for other imaging studies like a CT scan, not an intravenous pyelogram. Assisting with a bowel cleansing (choice D) is not typically required before an intravenous pyelogram.

5. A patient has scaling of the scalp. Which term will the nurse use to report this finding to the oncoming staff?

• A. Dandruff
• B. Alopecia
• C. Pediculosis
• D. Xerostomia

Correct answer: A

Rationale: The correct term the nurse will use to report scaling of the scalp is 'Dandruff.' Dandruff is characterized by scaling of the scalp that is often accompanied by itching. Choice B, 'Alopecia,' refers to hair loss, not scaling. Choice C, 'Pediculosis,' is the infestation of lice, not scaling. Choice D, 'Xerostomia,' pertains to dry mouth, which is unrelated to the described symptom of scaling of the scalp.

Similar Questions