Nursing Elites

1. A client with congestive heart failure is prescribed digoxin. What symptom indicates digoxin toxicity?

• A. Monitor for muscle weakness and fatigue.
• B. Monitor for increased appetite and weight gain.
• C. Monitor for nausea and vomiting.
• D. Monitor for blurred vision or seeing yellow halos around objects.

Correct answer: D

Rationale: Corrected Rationale: Blurred vision or seeing yellow halos around objects are signs of digoxin toxicity, which can be life-threatening. These symptoms indicate an overdose of digoxin, requiring immediate medical attention. Muscle weakness and fatigue (Choice A) are not typically associated with digoxin toxicity. Increased appetite and weight gain (Choice B) are not indicative of digoxin toxicity either. Nausea and vomiting (Choice C) are common side effects of digoxin but are not specific signs of toxicity. Therefore, the correct answer is to monitor for blurred vision or seeing yellow halos around objects.

2. A client with pheochromocytoma is admitted to the hospital. Which intervention has the highest priority?

• A. Monitor blood pressure frequently
• B. Start intravenous fluids at a fast rate
• C. Administer pain medication to reduce discomfort
• D. Give antihypertensive medications as prescribed

Correct answer: B

Rationale: The correct answer is B: Start intravenous fluids at a fast rate. In a client with pheochromocytoma, the highest priority intervention is to ensure adequate intravascular volume before initiating any other treatment. This helps prevent a sudden drop in blood pressure that can occur due to the release of catecholamines during tumor manipulation. While monitoring blood pressure frequently is essential, ensuring adequate intravascular volume takes precedence. Administering pain medication and antihypertensive medications are important but are not the highest priority in the initial management of pheochromocytoma.

3. A client is admitted with a suspected bowel obstruction. What assessment finding should the nurse report immediately?

• A. Absent bowel sounds in all quadrants.
• B. Distended abdomen with a firm, rigid feel.
• C. Frequent episodes of nausea and vomiting.
• D. Hyperactive bowel sounds and abdominal cramping.

Correct answer: B

Rationale: A distended abdomen with a firm, rigid feel is a concerning sign that suggests a complication such as bowel perforation, which requires immediate intervention. Absent bowel sounds can be expected in bowel obstructions but are not as urgent as a rigid abdomen. Frequent episodes of nausea and vomiting are common with bowel obstructions but do not indicate an immediate life-threatening complication. Hyperactive bowel sounds and abdominal cramping are more indicative of bowel obstruction rather than a complication requiring immediate attention.

4. A 5-week-old infant with hypertrophic pyloric stenosis has developed projectile vomiting over the last two weeks. Which intervention should the nurse plan to implement?

• A. Instruct the mother to give sugar water only.
• B. Offer the infant oral rehydration every 2 hours.
• C. Provide Pedialyte feedings via nasogastric tube.
• D. Maintain intravenous fluid therapy.

Correct answer: D

Rationale: The correct intervention for a 5-week-old infant with hypertrophic pyloric stenosis presenting with projectile vomiting is to maintain intravenous fluid therapy. This is essential to maintain hydration before surgery. Instructing the mother to give sugar water only (Choice A) is inadequate and does not address the need for proper hydration. Offering oral rehydration every 2 hours (Choice B) may not be effective in cases of severe vomiting and could lead to further fluid loss. Providing Pedialyte feedings via nasogastric tube (Choice C) is an option, but in severe cases, intravenous fluid therapy is more effective in ensuring hydration and electrolyte balance.

5. A client with heart failure is prescribed spironolactone. What is the nurse's priority intervention?

• A. Monitor the client's potassium levels closely.
• B. Assess for signs of hyperkalemia.
• C. Instruct the client to increase intake of potassium-rich foods.
• D. Increase the client’s fluid intake to prevent dehydration.

Correct answer: B

Rationale: The correct answer is B: Assess for signs of hyperkalemia. Spironolactone is a potassium-sparing diuretic, which can cause hyperkalemia (high potassium levels). Therefore, the nurse's priority intervention should be to assess the client for signs of hyperkalemia, such as muscle weakness, fatigue, and potentially dangerous cardiac arrhythmias. Monitoring potassium levels closely (choice A) is important but assessing for signs of hyperkalemia takes precedence. Instructing the client to increase intake of potassium-rich foods (choice C) can exacerbate hyperkalemia in this case. Increasing the client’s fluid intake to prevent dehydration (choice D) is not directly related to the potential side effect of spironolactone.

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