Nursing Elites

1. A female patient is discharged from the hospital after having an episode of heart failure. She's prescribed daily oral doses of digoxin (Lanoxin) and furosemide (Lasix). Two days later, she tells her community health nurse that she feels weak and her heart 'flutters' frequently. What action should the nurse take?

• A. Tell the patient to rest more frequently.
• B. Advise the patient to discontinue digoxin and contact the physician.
• C. Contact the physician, report the symptoms, and request a blood sample to determine the patient's potassium level.
• D. Instruct the patient to avoid caffeine-containing foods.

Correct answer: C

Rationale: The correct action for the nurse to take is to contact the physician, report the patient's symptoms, and request a blood sample to determine the patient's potassium level. Furosemide, a potassium-wasting diuretic, can lead to hypokalemia, causing weakness and palpitations. Therefore, checking the potassium level is crucial in this situation. Simply telling the patient to rest more frequently won't address the underlying issue of potassium depletion. While digoxin can cause adverse effects, in this case, the symptoms are more likely related to furosemide-induced potassium loss. Instructing the patient to avoid caffeine-containing foods may be beneficial in general, but it wouldn't directly address the potassium depletion that needs urgent attention.

2. You are the nurse caring for a patient who is to receive IV daunorubicin, a chemotherapeutic agent. You start the infusion and check the insertion site as per protocol. During your most recent check, you note that the IV has infiltrated so you stop the infusion. What is your main concern with this infiltration?

• A. Extravasation of the medication
• B. Discomfort to the patient
• C. Blanching at the site
• D. Hypersensitivity reaction to the medication

Correct answer: A

Rationale:

3. A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and feeling warm. For which complication of this therapy should the nurse assess this client?

• A. Allergic reaction
• B. Bowel obstruction
• C. Catheter lumen occlusion
• D. Infection

Correct answer: D

Rationale:

4. A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the clients chart prior to administering the medication: Client: Thomas Jackson DOB: 5/3/1936 Gender: Male January 23 (Today): Right uppe

• A. Notify the health care provider
• B. . Administer the prescribed medication.
• C. Discontinue the PICC
• D. Switch the medication to the oral route

Correct answer: B

Rationale:

5. Your patient has alcoholism, and you may suspect during your assessment that his serum magnesium is low. What will the nurse potentially expect to assess related to hypomagnesemia?

• A. Tremor
• B. Pruritus
• C. Edema
• D. Decreased blood pressure

Correct answer: A

Rationale: The correct answer is A: Tremor. Signs and symptoms of hypomagnesemia primarily affect the neuromuscular system and can include tremors, confusion, tetany, laryngeal stridor, and ataxia. Pruritus (choice B) refers to itching and is not typically associated with hypomagnesemia. Edema (choice C) is swelling caused by fluid retention and is not a common manifestation of hypomagnesemia. Decreased blood pressure (choice D) is not a typical sign of hypomagnesemia; instead, low magnesium levels are more likely to cause hypertension.

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