Nursing Elites

1. A nurse is caring for a client who has a prescription for digoxin. Which of the following laboratory values should the nurse monitor to identify an adverse effect of this medication?

• A. Potassium 3.5 mEq/L
• B. Sodium 140 mEq/L
• C. Calcium 9.5 mg/dL
• D. Magnesium 2.0 mEq/L

Correct answer: A

Rationale: The correct answer is A: Potassium 3.5 mEq/L. Digoxin can cause hypokalemia as an adverse effect. Monitoring potassium levels is crucial because low potassium levels can increase the risk of digoxin toxicity. Choices B, C, and D are incorrect as they are not directly associated with potential adverse effects of digoxin. Sodium levels are not typically affected by digoxin, calcium levels are not a primary concern with digoxin therapy, and magnesium levels are not the most important to monitor for digoxin adverse effects.

2. What is the first action to take for a patient experiencing a seizure?

• A. Administer anticonvulsant medication
• B. Protect the patient's head
• C. Insert an oral airway
• D. Restrain the patient

Correct answer: B

Rationale: The first action a nurse should take for a patient experiencing a seizure is to protect the patient's head. This is crucial to prevent head injuries during the seizure. Administering anticonvulsant medication may be necessary but is not the first action. Inserting an oral airway may cause injury as the patient may bite down during a seizure. Restraint is not recommended as it can lead to further harm.

3. A client with a new diagnosis of systemic lupus erythematosus (SLE) is being cared for by a nurse. Which of the following findings should the nurse expect?

• A. Joint pain.
• B. Weight gain.
• C. Butterfly-shaped rash on the face.
• D. Increased appetite.

Correct answer: B

Rationale: The correct answer is B: Weight gain. Weight gain is a common finding in clients with systemic lupus erythematosus due to fluid retention. Joint pain (choice A) is also common in SLE but is not specific to fluid retention. A butterfly-shaped rash on the face (choice C) is a classic symptom of SLE but is not related to fluid retention. Increased appetite (choice D) is less likely in SLE compared to weight gain.

4. A healthcare provider is assessing a client who has heart failure and is taking digoxin. Which of the following findings should the healthcare provider identify as an indication of digoxin toxicity?

• A. Bradycardia.
• B. Yellow-tinged vision.
• C. Constipation.
• D. Hypertension.

Correct answer: B

Rationale: Yellow-tinged vision is a classic sign of digoxin toxicity due to its effect on the eyes. It can cause a yellow or green visual halo around objects. Bradycardia, constipation, and hypertension are not typical signs of digoxin toxicity. Bradycardia may be a sign of digoxin's therapeutic effect in heart failure, while constipation and hypertension are not commonly associated with digoxin toxicity.

5. A nurse is preparing to administer a blood transfusion to a client. Which of the following actions should the nurse take?

• A. Monitor the client's vital signs every 4 hours.
• B. Start the transfusion with 0.9% sodium chloride.
• C. Administer the transfusion over 6 hours.
• D. Infuse the first 500 mL of blood over 1 hour.

Correct answer: B

Rationale: The correct answer is B: Start the transfusion with 0.9% sodium chloride. 0.9% sodium chloride is the only IV solution that is compatible with blood products and should be used to prime the tubing before a transfusion. Choice A is incorrect because vital signs should be monitored more frequently, typically every 15 minutes at the beginning of the transfusion. Choice C is incorrect as blood transfusions are usually administered over 2-4 hours, not 6 hours. Choice D is incorrect as the first 500 mL of blood should be infused slowly over 1-2 hours to monitor for any adverse reactions.

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