Nursing Elites

1. A client with a history of congestive heart failure (CHF) is receiving digoxin (Lanoxin). The nurse should monitor the client for which sign of digoxin toxicity?

• A. Hypertension
• B. Bradycardia
• C. Hyperglycemia
• D. Insomnia

Correct answer: B

Rationale: Bradycardia is a common sign of digoxin toxicity. Digoxin can cause bradycardia due to its effects on the heart's electrical conduction system. The nurse should closely monitor the client's heart rate for any signs of slowing down, as it can indicate toxicity and potentially lead to serious complications. Hypertension, hyperglycemia, and insomnia are not typically associated with digoxin toxicity. Hypertension is more commonly associated with other conditions or medications, hyperglycemia can be seen in conditions like diabetes or certain medications, and insomnia is not a typical sign of digoxin toxicity.

2. A client in the emergency department is bleeding profusely from a gunshot wound to the abdomen. In what position should the nurse immediately place the client to promote maintenance of the client's blood pressure above a systolic pressure of 90 mm Hg?

• A. Place the client in a 45-degree Trendelenburg position to promote cerebral blood flow.
• B. Turn the client prone to apply pressure on the abdominal wound to help staunch the bleeding.
• C. Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the wound.
• D. Put the client on the right side to apply pressure to the liver and spleen to stop hemorrhaging.

Correct answer: C

Rationale: In a client with profuse bleeding from a gunshot wound to the abdomen, maintaining the client in a supine position is essential to manage blood pressure. This position helps in reducing diaphragmatic pressure and allows for proper visualization of the wound, aiding in prompt assessment and intervention to control the bleeding and stabilize the client's condition. Placing the client in a 45-degree Trendelenburg position (Choice A) could worsen the bleeding by increasing intrathoracic pressure and venous return, potentially leading to further hemorrhage. Turning the client prone (Choice B) may not be feasible in this situation and can delay essential interventions. Placing the client on the right side (Choice D) does not address the immediate need to manage the bleeding and stabilize the client's condition.

3. The LPN/LVN is assisting in the care of a client who has been prescribed enoxaparin (Lovenox) for the prevention of deep vein thrombosis (DVT). Which instruction should the nurse reinforce with the client?

• A. Avoid consuming foods high in vitamin K while taking this medication.
• B. Administer the injection in the same site each time for consistency.
• C. Report any unusual bleeding or bruising to your healthcare provider.
• D. Do not take aspirin if you experience any mild pain or discomfort.

Correct answer: C

Rationale: The correct instruction for the nurse to reinforce with the client is to report any unusual bleeding or bruising to their healthcare provider. This is crucial because unusual bleeding or bruising may indicate excessive anticoagulation, a potential side effect of enoxaparin. Prompt reporting to a healthcare provider is necessary to prevent complications. Choices A, B, and D are incorrect. Choice A is not directly related to enoxaparin and vitamin K interactions. Choice B is incorrect as rotating injection sites is essential for preventing tissue damage and irritation. Choice D is also incorrect as aspirin can increase the risk of bleeding when taken with enoxaparin.

4. A client with a history of chronic heart failure is being discharged. Which instruction should the nurse include in the discharge teaching?

• A. Weigh yourself daily and report a weight gain of 2 pounds or more in a day.
• B. Restrict fluid intake to 2000 mL per day.
• C. Increase your salt intake to prevent electrolyte imbalance.
• D. Exercise vigorously at least three times a week.

Correct answer: A

Rationale: The correct answer is to weigh yourself daily and report a weight gain of 2 pounds or more in a day. This instruction is crucial because daily weights help in early detection of fluid retention, a common complication in heart failure. Monitoring weight is essential for managing heart failure and preventing exacerbations. Choice B is incorrect because fluid restriction may be necessary in some cases of heart failure, but a general limit of 2000 mL per day is not appropriate without individual assessment. Choice C is incorrect as increasing salt intake can worsen fluid retention and exacerbate heart failure symptoms. Choice D is incorrect because while exercise is beneficial for heart health, vigorous exercise may not be suitable for all heart failure patients and should be tailored to their specific condition.

5. Which laboratory test should be monitored to evaluate the effectiveness of anticoagulant therapy in a client with deep vein thrombosis (DVT)?

• A. Complete blood count (CBC)
• B. Activated partial thromboplastin time (aPTT)
• C. Serum electrolytes
• D. Liver function tests

Correct answer: B

Rationale: Activated partial thromboplastin time (aPTT) is the laboratory test monitored to evaluate the effectiveness of anticoagulant therapy, particularly with heparin. It measures the time it takes for blood to clot, and monitoring aPTT helps ensure the therapeutic range is maintained to prevent clot formation and excessive bleeding. Choices A, C, and D are incorrect because a complete blood count (CBC) assesses overall health, serum electrolytes evaluate the body's electrolyte balance, and liver function tests assess liver health, none of which directly evaluate the effectiveness of anticoagulant therapy for DVT.

Similar Questions