Nursing Elites

1. A client with heart failure is receiving digoxin. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 78/min.
• B. Vision changes.
• C. Respiratory rate of 16/min.
• D. Blood pressure of 120/80 mm Hg.

Correct answer: B

Rationale: The correct answer is B: Vision changes. Vision changes are a classic sign of digoxin toxicity and should be reported immediately to the provider for further evaluation and management. A heart rate of 78/min, a respiratory rate of 16/min, and a blood pressure of 120/80 mm Hg are within normal ranges and are not typically associated with digoxin toxicity. Therefore, they would not be the priority findings to report in this situation.

2. A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks the nurse about becoming a living kidney donor for her father. Which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure?

• A. Amputation.
• B. Osteoarthritis.
• C. Hypertension.
• D. Primary glaucoma.

Correct answer: C

Rationale: Hypertension is a contraindication for kidney donation because it can negatively impact the donor's health in the long term. Hypertension poses risks during and after the donation procedure, such as affecting kidney function and potentially leading to complications for both the donor and the recipient. Amputation, osteoarthritis, and primary glaucoma are not direct contraindications for kidney donation and would not typically prevent someone from being a living kidney donor.

3. What is the best intervention for a patient experiencing respiratory distress?

• A. Administer oxygen
• B. Administer bronchodilators
• C. Administer IV fluids
• D. Provide humidified air

Correct answer: A

Rationale: Administering oxygen is the best intervention for a patient experiencing respiratory distress because it helps improve oxygenation and alleviate respiratory distress. Oxygen therapy is a critical and priority intervention in such cases as it aims to increase oxygen levels in the blood. Administering bronchodilators may be beneficial for specific respiratory conditions like asthma or COPD, but oxygen should be the initial priority. Administering IV fluids and providing humidified air, while important in certain situations, are not the primary interventions for respiratory distress.

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

• A. Infuse the PRBCs over 8 hours.
• B. Verify the client's blood type and Rh factor.
• C. Administer the PRBCs through a 24-gauge catheter.
• D. Administer the PRBCs with lactated Ringer's solution.

Correct answer: B

Rationale: Verifying the client's blood type and Rh factor is crucial before administering blood products to ensure compatibility and prevent adverse reactions. Option A is incorrect because PRBCs are typically infused over a specific time frame based on hospital policy and client condition, not necessarily over 8 hours. Option C is incorrect as PRBCs are usually administered through a larger gauge catheter to prevent hemolysis. Option D is incorrect because PRBCs are typically administered with normal saline and not lactated Ringer's solution.

5. A healthcare provider is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which finding should the healthcare provider identify as a contraindication to the administration of clozapine?

• A. Heart rate 58/min.
• B. Fasting blood glucose 100 mg/dL.
• C. Hgb 14 g/dL.
• D. WBC count 2,900/mm3.

Correct answer: D

Rationale: The correct answer is D: a low WBC count. Clozapine can suppress bone marrow function, leading to a decreased white blood cell count. This condition, known as agranulocytosis, increases the risk of severe infections. Monitoring WBC counts is essential during clozapine therapy. Choices A, B, and C are within normal ranges and are not contraindications for administering clozapine.

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