Nursing Elites

1. A client is receiving digoxin therapy. Which of the following should the nurse monitor?

• A. Liver function
• B. Serum electrolytes
• C. Blood pressure
• D. All of the above

Correct answer: D

Rationale: When a client is receiving digoxin therapy, it is crucial for the nurse to monitor liver function, serum electrolytes (especially potassium levels), and blood pressure. Digoxin is known to affect the heart's electrical activity and can lead to toxic effects if not managed properly. Monitoring liver function helps to assess the drug's metabolism and excretion. Checking serum electrolytes, especially potassium, is essential because digoxin toxicity can be exacerbated by electrolyte imbalances, particularly hypokalemia. Monitoring blood pressure is necessary because digoxin can influence cardiac contractility and heart rate, potentially affecting blood pressure. Therefore, monitoring all these parameters is vital to ensure the client's safety and therapeutic effectiveness of digoxin. Choices A, B, and C are incorrect because monitoring only one or two of these parameters may not provide a comprehensive assessment of the client's response to digoxin therapy.

2. A nurse is caring for a client who is in active labor. The nurse notes early decelerations in the FHR on the fetal monitor tracing. The nurse should identify that which of the following conditions causes early decelerations in the FHR?

• A. Fetal hypoxemia
• B. Cord compression
• C. Uteroplacental insufficiency
• D. Head compression

Correct answer: D

Rationale: Early decelerations are caused by head compression during contractions, which is a normal response as the fetal head is being compressed during uterine contractions. This usually indicates that the fetus is descending into the birth canal. Choices A, B, and C are incorrect. Fetal hypoxemia, cord compression, and uteroplacental insufficiency typically present with variable or late decelerations on the fetal heart rate tracing, not early decelerations.

3. A nurse is caring for a client who has mild anxiety. Which of the following findings should the nurse expect?

• A. Feelings of dread
• B. Rapid speech
• C. Purposeless activity
• D. Heightened perceptual field

Correct answer: D

Rationale: In mild anxiety, the client is expected to have a heightened perceptual field. This means that their perception is increased, enhancing their awareness and ability to concentrate. Feelings of dread (Choice A) are more common in moderate to severe anxiety. Rapid speech (Choice B) and purposeless activity (Choice C) are more indicative of moderate to severe anxiety where the individual may exhibit signs of agitation and restlessness.

4. A nurse is planning care for a newly admitted adolescent with bacterial meningitis. What intervention should the nurse include?

• A. Initiate droplet precautions
• B. Assist the client to a supine position
• C. Perform a Glasgow Coma Scale every 24 hours
• D. Recommend prophylactic acyclovir for the client's family

Correct answer: A

Rationale: The correct intervention for a newly admitted adolescent with bacterial meningitis is to initiate droplet precautions. Bacterial meningitis is highly contagious, and droplet precautions are necessary to prevent the spread of infection. Assisting the client to a supine position (Choice B) is not directly related to managing bacterial meningitis. Performing a Glasgow Coma Scale every 24 hours (Choice C) may be important to assess the client's neurological status but is not the priority intervention in preventing the spread of infection. Recommending prophylactic acyclovir for the client's family (Choice D) is not a standard practice in the care of a patient with bacterial meningitis.

5. A nurse is caring for a client who has been receiving oxytocin IV for labor augmentation. The client's contractions are occurring every 2 minutes and lasting 90 seconds. What action should the nurse take?

• A. Decrease the oxytocin infusion
• B. Discontinue the oxytocin infusion
• C. Increase the IV fluid rate
• D. Apply an internal fetal monitor

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to discontinue the oxytocin infusion. The client is experiencing uterine hyperstimulation, as evidenced by contractions occurring every 2 minutes and lasting 90 seconds. Discontinuing the oxytocin is crucial to prevent fetal distress and uterine rupture. Increasing the IV fluid rate would not address the uterine hyperstimulation caused by oxytocin. Applying an internal fetal monitor is not the priority at this moment; first, the oxytocin infusion needs to be stopped to manage the uterine hyperstimulation effectively.

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