Nursing Elites

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

• A. Heart rate 68/min.
• B. Blood pressure 110/70 mm Hg.
• C. Vision changes.
• D. Respiratory rate 18/min.

Correct answer: C

Rationale: Corrected Rationale: Vision changes are a common sign of digoxin toxicity, which can be serious and should be reported to the provider immediately. Changes in heart rate, blood pressure, or respiratory rate are not typically associated with digoxin toxicity. Therefore, the nurse should prioritize reporting vision changes to ensure prompt assessment and intervention.

2. A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which of the following interventions should the nurse include?

• A. Massage the affected extremity every 4 hours.
• B. Encourage the client to remain on bed rest.
• C. Apply cold packs to the affected extremity.
• D. Encourage the client to ambulate frequently.

Correct answer: C

Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to apply cold packs to the affected extremity. Cold packs help reduce swelling and pain by causing vasoconstriction. Massaging the affected extremity could dislodge a clot, leading to serious complications. Encouraging bed rest may increase the risk of clot propagation, while frequent ambulation is contraindicated as it can dislodge clots.

3. A healthcare professional is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the professional make in the medical record?

• A. Morphine 3 mg SC every 4 hr. PRN for pain
• B. Morphine 3 mg Subcutaneous
• C. Morphine 3.0 mg subq every 4 hr. PRN for pain
• D. Morphine 3 mg SC q 4 hr. PRN for pain

Correct answer: A

Rationale: The correct entry for the medication in the medical record should include the abbreviation 'SC' (subcutaneous) for the route of administration. Choice A is the correct answer as it accurately represents the prescription received. Choice B is incorrect because it lacks the frequency and PRN indication. Choice C is incorrect due to the incorrect abbreviation 'subq' and the missing 'q' before the frequency. Choice D is incorrect because it uses 'SC' but the frequency abbreviation 'q' should be followed by the time interval.

4. A client is being discharged with a new prescription for levothyroxine. Which of the following instructions should the nurse include?

• A. Take this medication with meals to avoid stomach upset.
• B. Take this medication at the same time every day.
• C. Notify your provider if you experience chest pain or palpitations.
• D. Take this medication with antacids to reduce indigestion.

Correct answer: B

Rationale: The correct answer is B: 'Take this medication at the same time every day.' It is crucial to take levothyroxine at the same time each day to maintain consistent thyroid hormone levels. Choice A is incorrect because levothyroxine should be taken on an empty stomach, usually in the morning. Choice C is important but not specific to the administration of levothyroxine. Choice D is incorrect as antacids can interfere with the absorption of levothyroxine.

5. A nurse is caring for a client who is 1 day postoperative following a total knee replacement. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 88/min
• B. Serous drainage on the dressing
• C. Temperature 37.3°C (99.1°F)
• D. Calf pain on dorsiflexion

Correct answer: D

Rationale: The correct answer is D. Calf pain on dorsiflexion following knee surgery may indicate a complication such as deep vein thrombosis, which is a serious condition requiring medical attention. Reporting this finding promptly is crucial to prevent further complications. Choices A, B, and C are within normal range for a client post knee surgery and do not typically indicate immediate complications that require urgent reporting.

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