Nursing Elites

1. A client with heart failure is prescribed digoxin. What assessment finding should the nurse report immediately?

• A. Bradycardia of 50 beats per minute.
• B. Heart rate of 110 beats per minute.
• C. Respiratory rate of 16 breaths per minute.
• D. Blood pressure of 130/80 mmHg.

Correct answer: A

Rationale: The correct answer is A: Bradycardia of 50 beats per minute. Bradycardia is a critical assessment finding in a client prescribed with digoxin, as it can indicate digoxin toxicity. Bradycardia is a known side effect of digoxin, and if left unaddressed, it can lead to serious complications such as arrhythmias or cardiac arrest. Both choices B, heart rate of 110 beats per minute, and C, respiratory rate of 16 breaths per minute, fall within normal ranges and do not raise immediate concerns. Choice D, blood pressure of 130/80 mmHg, is also within normal limits and does not indicate digoxin toxicity. Therefore, the nurse should report bradycardia promptly to prevent further complications.

2. Which of the following statements reflects appropriate teaching to prevent injury in a client with rheumatoid arthritis?

• A. Use heat applications to relieve swelling and stiffness.
• B. Take warm showers before activity.
• C. Use cold packs to relieve joint pain.
• D. Take prescribed anti-inflammatory medications with meals.

Correct answer: C

Rationale: The correct answer is C. Using cold packs to relieve joint pain is appropriate for clients with rheumatoid arthritis as cold therapy is more effective at reducing inflammation and pain in these conditions. Heat applications may exacerbate the symptoms by increasing swelling. Taking warm showers before activity may provide comfort but does not directly address joint pain or prevent injury. While anti-inflammatory medications are commonly prescribed, they are not directly related to preventing injury in clients with rheumatoid arthritis.

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

• A. Absence of bowel sounds in all four quadrants.
• B. Abdominal distention with a firm, rigid abdomen.
• C. Frequent, small, liquid stools.
• D. Nausea and vomiting that worsens after meals.

Correct answer: B

Rationale: Abdominal distention with a firm, rigid abdomen is a concerning sign that may indicate perforation, which requires immediate intervention. The rigidity suggests a complication of the large bowel obstruction. Absence of bowel sounds in all four quadrants, option A, is a common finding in a bowel obstruction but not as alarming as a rigid abdomen. Frequent, small, liquid stools, option C, are not typical findings in a large bowel obstruction; instead, constipation is more common. Nausea and vomiting that worsens after meals, option D, are also common symptoms of a bowel obstruction but do not indicate an immediate life-threatening complication like a perforation.

4. Following a lumbar puncture, a client complains of worsening headache when sitting up. What complication is the client likely experiencing?

• A. A migraine headache
• B. An infection from the puncture site
• C. Low blood sugar
• D. Spinal fluid leakage (post-lumbar puncture headache)

Correct answer: D

Rationale: The client is likely experiencing spinal fluid leakage (post-lumbar puncture headache), a common complication of a lumbar puncture. This leakage results in a reduction of cerebrospinal fluid volume around the brain and spinal cord, leading to a headache that worsens when in an upright position due to reduced buoyancy. A migraine headache (Choice A) is not typically associated with a lumbar puncture. Infection from the puncture site (Choice B) would present with localized signs of inflammation, such as redness, swelling, and warmth, rather than worsening headache. Low blood sugar (Choice C) is not a common complication of lumbar puncture and would not typically manifest as a worsening headache when sitting up.

5. A client is admitted with ascites, malnutrition, and recent complaints of spitting up blood. What assessment finding warrants immediate intervention by the nurse?

• A. Capillary refill of 8 seconds
• B. Bruises on arms and legs
• C. Round and tight abdomen
• D. Pitting edema in lower legs

Correct answer: C

Rationale: A round and tight abdomen suggests fluid accumulation from ascites, which could signal a more severe underlying condition requiring immediate intervention. This finding indicates increased intra-abdominal pressure, which can lead to respiratory compromise or other serious complications. Capillary refill time, bruises on arms and legs, and pitting edema in the lower legs are important assessments but do not directly indicate the need for immediate intervention as a round and tight abdomen does in this case.

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