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. While caring for a client in active labor, a nurse notes late decelerations in the FHR on the external fetal monitor. Which of the following actions should the nurse take first?

• A. Change the client's position
• B. Palpate the uterus to assess for tachysystole
• C. Increase the client's IV infusion rate
• D. Administer oxygen at 10 L/min via nonrebreather mask

Correct answer: A

Rationale: The correct initial action for the nurse to take is to change the client's position. This intervention can alleviate pressure on the umbilical cord, potentially improving fetal oxygenation and addressing the underlying cause of late decelerations. Palpating the uterus to assess for tachysystole or increasing the IV infusion rate are not the first-line interventions for addressing late decelerations. Administering oxygen at a high flow rate via a nonrebreather mask may be necessary but is not the priority action in this situation.

3. A nurse is caring for a client with a history of substance abuse. Which of the following interventions should the nurse prioritize?

• A. Monitor for withdrawal symptoms
• B. Encourage social activities
• C. Schedule regular follow-ups
• D. Provide educational materials

Correct answer: A

Rationale: The correct answer is to monitor for withdrawal symptoms. This is a priority because individuals with a history of substance abuse are at risk of experiencing withdrawal symptoms when the substance is no longer used. Monitoring for withdrawal symptoms is crucial to ensure the client's safety and to manage any potential complications related to substance withdrawal. Encouraging social activities, scheduling regular follow-ups, and providing educational materials are also important aspects of care, but they are not as critical as monitoring for withdrawal symptoms in this immediate scenario.

4. A nurse is assessing a client who reports chest pain. Which of the following findings should cause the nurse to suspect a myocardial infarction?

• A. Pain improves with rest
• B. Pain radiates to the left arm.
• C. Pain worsens with deep breathing.
• D. Pain is relieved by antacids.

Correct answer: B

Rationale: The correct answer is B. Radiating pain, especially to the left arm, is a classic sign of myocardial infarction. Pain that radiates to the left arm indicates cardiac involvement, making it a significant finding. Choices A, C, and D are incorrect because chest pain that improves with rest, worsens with deep breathing, or is relieved by antacids is less likely to be associated with a myocardial infarction.

5. A nurse is assessing four clients for fluid balance. Which of the following clients is exhibiting manifestations of dehydration?

• A. A client who has a urine specific gravity of 1.010.
• B. A client who has a weight gain of 2.2 kg (2 lb) in 24 hr.
• C. A client who has a hematocrit of 45%.
• D. A client who has a temperature of 39°C (102°F).

Correct answer: D

Rationale: The correct answer is D because an elevated temperature is a common manifestation of dehydration. Choices A, B, and C are not indicative of dehydration. A urine specific gravity of 1.010 is within normal range, weight gain suggests fluid overload, and a hematocrit of 45% is also within normal limits and not specifically related to dehydration.

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