Nursing Elites

1. A client with heart failure is prescribed digoxin and reports nausea. What is the nurse's first action?

• A. Administer an anti-nausea medication as prescribed.
• B. Assess the client's digoxin level immediately.
• C. Assess the client’s apical pulse and hold the next dose if it's below 60 bpm.
• D. Instruct the client to reduce their fluid intake.

Correct answer: B

Rationale: When a client on digoxin reports nausea, it can be a sign of digoxin toxicity. The priority action for the nurse is to assess the client's digoxin level immediately. This assessment will help determine if the nausea is related to digoxin toxicity, requiring a dosage adjustment. Administering an anti-nausea medication (Choice A) does not address the underlying issue of potential digoxin toxicity. Assessing the client's apical pulse (Choice C) is important in general digoxin monitoring but not the first action when nausea is reported. Instructing the client to reduce fluid intake (Choice D) is not the initial response to nausea in a client taking digoxin.

2. A client with a history of adrenal insufficiency is admitted with acute adrenal crisis. The client complains of nausea and joint pain, vital signs show a temperature of 102°F, heart rate of 138, and blood pressure of 80/60. Which intervention should the nurse implement first?

• A. Obtain an analgesic prescription.
• B. Infuse an intravenous fluid bolus.
• C. Administer PRN oral antipyretic.
• D. Cover the client with a cooling blanket.

Correct answer: B

Rationale: In acute adrenal crisis, the priority intervention is to infuse an intravenous fluid bolus to address the hypotension (blood pressure of 80/60) and help stabilize the client's condition. Adequate fluid volume is crucial in managing adrenal insufficiency crisis. Options A, C, and D do not directly address the hypotension and fluid volume depletion that are critical in this situation. Analgesics, antipyretics, and cooling blankets may be considered later, but the immediate focus should be on fluid resuscitation.

3. A client is receiving treatment for glaucoma. Which class of medications is commonly used to decrease intraocular pressure?

• A. Anticholinergics
• B. Beta blockers
• C. Alpha blockers
• D. Diuretics

Correct answer: D

Rationale: Diuretics are commonly used to decrease intraocular pressure in clients with glaucoma. They work by reducing the production of aqueous humor in the eye or by increasing its outflow. Anticholinergics (Choice A) are not typically used in the treatment of glaucoma and can even increase intraocular pressure. Beta blockers (Choice B) are also commonly used in glaucoma treatment as they reduce aqueous humor production. Alpha blockers (Choice C) are not the first-line treatment for glaucoma and are not as commonly used as diuretics or beta blockers.

4. After receiving a report on an inpatient acute care unit, which client should the nurse assess first?

• A. Client with pneumonia who has a fever of 101.5°F
• B. Client who underwent knee surgery and needs dressing change
• C. Client with a bowel obstruction due to a volvulus experiencing abdominal rigidity
• D. Client with diabetes requesting insulin

Correct answer: C

Rationale: The correct answer is C. Abdominal rigidity in a client with a bowel obstruction could indicate peritonitis, a serious complication requiring immediate attention. Volvulus, a twisting of the intestine, can lead to bowel ischemia and necrosis. Clients with pneumonia (choice A) may need assessment and treatment for infection, but it is not as immediately life-threatening as a bowel obstruction. A client who underwent knee surgery (choice B) needing a dressing change can typically wait for assessment compared to a potential surgical emergency. Similarly, a client with diabetes requesting insulin (choice D) may require attention to maintain blood glucose levels, but it is not as urgent as a suspected bowel obstruction with possible peritonitis.

5. An adult client with a broken femur reports muscle spasms. What action should the nurse implement while awaiting surgery?

• A. Check the client's most recent electrolyte levels.
• B. Administer a PRN dose of muscle relaxant.
• C. Reduce the weight on the traction device.
• D. Encourage oral fluid intake to relieve muscle tension.

Correct answer: D

Rationale: The correct action for the nurse to implement while awaiting surgery for a client with muscle spasms due to a broken femur is to encourage oral fluid intake to relieve muscle tension. Dehydration can exacerbate muscle spasms, so increasing fluid intake can help alleviate them. Checking electrolyte levels may not directly address muscle spasms in this situation. Administering a muscle relaxant should be based on a healthcare provider's prescription, and traction weight adjustments should only be made by the provider overseeing the client's care.

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