Nursing Elites

1. A client with heart failure is receiving digoxin. Which finding should indicate to the nurse that the client is experiencing digoxin toxicity?

• A. Constipation
• B. Blurred vision
• C. Bradycardia
• D. Dry cough

Correct answer: C

Rationale: Bradycardia is a hallmark sign of digoxin toxicity. Digoxin, a medication used to treat heart conditions, can lead to toxicity manifesting as bradycardia. Bradycardia occurs due to the drug's effect on slowing down the heart rate excessively. Constipation (Choice A) is not typically associated with digoxin toxicity. Blurred vision (Choice B) is more commonly linked to visual disturbances caused by digoxin, but it is not a defining sign of toxicity. Dry cough (Choice D) is not a recognized symptom of digoxin toxicity. It is crucial for the nurse to recognize the early signs of digoxin toxicity to prevent serious complications and provide appropriate interventions promptly.

2. A client has a new prescription for furosemide. Which of the following statements should the nurse include in the teaching?

• A. Take the medication in the morning.
• B. Monitor for muscle weakness.
• C. Eat foods high in potassium.
• D. Expect weight gain.

Correct answer: C

Rationale: The correct statement that the nurse should include in the teaching for a client prescribed furosemide is to eat foods high in potassium. Furosemide can lead to potassium depletion (hypokalemia) due to increased urine output. Consuming potassium-rich foods like bananas, oranges, spinach, and potatoes can help prevent this electrolyte imbalance. Choices A, B, and D are incorrect because taking furosemide in the morning, monitoring for muscle weakness, and expecting weight gain are not directly related to the potential side effects or necessary dietary adjustments when taking furosemide.

3. A client with a history of chronic heart failure is being discharged. Which instruction should the nurse include in the discharge teaching?

• A. Weigh yourself daily and report a weight gain of 2 pounds or more in a day.
• B. Restrict fluid intake to 2000 mL per day.
• C. Increase your salt intake to prevent electrolyte imbalance.
• D. Exercise vigorously at least three times a week.

Correct answer: A

Rationale: The correct answer is to weigh yourself daily and report a weight gain of 2 pounds or more in a day. This instruction is crucial because daily weights help in early detection of fluid retention, a common complication in heart failure. Monitoring weight is essential for managing heart failure and preventing exacerbations. Choice B is incorrect because fluid restriction may be necessary in some cases of heart failure, but a general limit of 2000 mL per day is not appropriate without individual assessment. Choice C is incorrect as increasing salt intake can worsen fluid retention and exacerbate heart failure symptoms. Choice D is incorrect because while exercise is beneficial for heart health, vigorous exercise may not be suitable for all heart failure patients and should be tailored to their specific condition.

4. A healthcare professional is preparing to administer a unit of packed red blood cells to a client. Which of the following actions should the healthcare professional take?

• A. Prime the blood tubing with normal saline.
• B. Verify the client’s identity using two identifiers.
• C. Infuse the blood rapidly over 30 minutes.
• D. Obtain the client’s vital signs every 4 hours during the transfusion.

Correct answer: B

Rationale: Verifying the client’s identity using two identifiers is a critical patient safety measure to ensure the correct patient receives the blood transfusion. This process involves checking the patient's identity using at least two unique identifiers, such as name, date of birth, or medical record number, to prevent administration errors. Priming the blood tubing with normal saline is necessary to ensure there are no air bubbles in the tubing, but it is not the immediate action required before administering the blood. Infusing packed red blood cells over 30 minutes is generally too rapid and can lead to adverse reactions; a slower rate is recommended for safe administration. Obtaining vital signs every 4 hours during the transfusion is not frequent enough to monitor the client adequately for potential transfusion reactions or complications; vital signs should be monitored more frequently, especially during the initial phase of the transfusion.

5. A client is admitted to the hospital with a diagnosis of myocardial infarction (MI). Which diagnostic test is most likely to be ordered to confirm this diagnosis?

• A. Echocardiogram
• B. Electrocardiogram (ECG)
• C. Chest X-ray
• D. Complete blood count (CBC)

Correct answer: B

Rationale: An Electrocardiogram (ECG) is the primary diagnostic tool used to confirm a myocardial infarction. An ECG provides immediate information on cardiac function and can show characteristic changes indicative of a myocardial infarction, such as ST-segment elevation or depression. An echocardiogram (Choice A) is useful for assessing heart structure and function but is not typically used as the primary test for confirming an acute myocardial infarction. Chest X-ray (Choice C) may show certain changes in heart size or pulmonary congestion but is not the primary diagnostic test for MI. A Complete Blood Count (CBC) (Choice D) provides information about the cellular components of blood and is not specific to confirming a myocardial infarction.

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