Nursing Elites

1. A client with heart failure is receiving digoxin (Lanoxin). Which finding indicates that the medication is effective?

• A. Increased heart rate.
• B. Decreased pedal edema.
• C. Elevated blood pressure.
• D. Improved urine output.

Correct answer: B

Rationale: In a client with heart failure, decreased pedal edema is a positive indicator of improved cardiac output and reduced fluid retention. Digoxin works by increasing the strength of the heart's contractions, leading to improved circulation and reduced symptoms of heart failure, such as edema. Monitoring for decreased pedal edema is essential to assess the effectiveness of digoxin therapy. Choices A, C, and D are incorrect because an increased heart rate, elevated blood pressure, and improved urine output are not specific indicators of digoxin's effectiveness in managing heart failure. Instead, the focus should be on improvements related to fluid retention and cardiac function, like decreased pedal edema.

2. A patient with atrial fibrillation is prescribed warfarin. Which laboratory test should the nurse monitor to assess the effectiveness of the medication?

• A. Complete blood count (CBC)
• B. Prothrombin time (PT)/INR
• C. Partial thromboplastin time (PTT)
• D. Serum potassium level

Correct answer: B

Rationale: The correct answer is B: Prothrombin time (PT)/INR. Warfarin affects the clotting ability of the blood by inhibiting vitamin K-dependent clotting factors. Monitoring the prothrombin time (PT) and international normalized ratio (INR) is crucial to assess the effectiveness and safety of warfarin therapy. These tests help determine if the patient is within the desired anticoagulation range to prevent either clotting issues or excessive bleeding.

3. The nurse formulates a nursing diagnosis of 'High risk for ineffective airway clearance' for a client with myasthenia gravis. What is the most likely etiology for this nursing diagnosis?

• A. Pain when coughing.
• B. Diminished cough effort.
• C. Thick, dry secretions.
• D. Excessive inflammation.

Correct answer: B

Rationale: The correct answer is B: Diminished cough effort. Clients with myasthenia gravis often experience muscle weakness, including respiratory muscles, which can lead to diminished cough effort. This weakness can result in ineffective airway clearance, putting the client at a high risk. Pain when coughing (choice A) is not directly related to the etiology of ineffective airway clearance in myasthenia gravis. While thick, dry secretions (choice C) and excessive inflammation (choice D) can contribute to airway clearance issues, the primary concern in myasthenia gravis is the muscle weakness affecting cough effort.

4. The client with bacterial pneumonia is receiving intravenous antibiotics. Which assessment finding indicates that the treatment is effective?

• A. Increased respiratory rate.
• B. Decreased oxygen saturation.
• C. Clear lung sounds.
• D. Elevated white blood cell count.

Correct answer: C

Rationale: Clear lung sounds indicate that the antibiotics are effectively treating the bacterial pneumonia by resolving the infection and reducing the inflammation in the lungs, leading to improved air exchange and ventilation. Increased respiratory rate (Choice A) and decreased oxygen saturation (Choice B) are indicative of ongoing respiratory distress and ineffective treatment. Elevated white blood cell count (Choice D) suggests a persistent infection rather than effective treatment.

5. When working with a client who has chronic constipation, what should be included in client teaching to promote normal bowel function?

• A. Use glycerin suppositories on a regular basis
• B. Limit physical activity in order to promote bowel peristalsis
• C. Consume high-residue, high-fiber foods
• D. Resist the urge to defecate until the urge becomes intense

Correct answer: C

Rationale: Consuming high-residue, high-fiber foods is essential in promoting normal bowel function and preventing constipation. These foods help add bulk to the stool, making it easier to pass and preventing constipation. Glycerin suppositories may provide short-term relief but are not a long-term solution for chronic constipation. Physical activity actually helps promote bowel peristalsis, so limiting it would not be beneficial. Delaying defecation can lead to stool hardening and worsening constipation.

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