a nurse is caring for a client who has heart failure and is receiving digoxin which of the following findings should the nurse report to the provider
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam

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

Correct answer: B

Rationale: The correct answer is B. A blood pressure of 110/70 mm Hg is a finding that the nurse should report to the provider when caring for a client with heart failure receiving digoxin. Digoxin can cause hypotension, so a low blood pressure reading should be reported promptly to the provider for further evaluation and management. Choices A, C, and D are within normal ranges and would not require immediate reporting. A heart rate of 60/min is considered normal, but any further decrease should be monitored. A serum potassium level of 4 mEq/L is also within the normal range. A blood pressure of 120/80 mm Hg is typically considered normal as well.

2. A client is receiving intermittent tube feedings and is at risk for aspiration. What should the nurse identify as a risk factor?

Correct answer: B

Rationale: The correct answer is B: History of gastroesophageal reflux disease. Gastroesophageal reflux disease increases the risk of aspiration due to the potential for regurgitation of stomach contents into the esophagus and airways. Choices A, C, and D are not directly related to an increased risk of aspiration. A residual of 65mL 1 hour postprandial may indicate delayed gastric emptying but is not a direct risk factor for aspiration. Receiving a high-osmolarity formula or receiving a feeding in a supine position are not specific risk factors for aspiration unless they contribute to reflux or other related issues.

3. A nurse is caring for a client who speaks a language different from the nurse. Which of the following actions should the nurse take?

Correct answer: D

Rationale: The correct action for the nurse to take when caring for a client who speaks a different language is to review the facility policy about the use of an interpreter. This ensures compliance with best practices for communication when using interpreters, maintaining accuracy and confidentiality. Requesting an interpreter of a different sex from the client (Choice A) is not relevant to effective communication. Asking a family member or friend to interpret (Choice B) can lead to misinterpretation or breach of confidentiality. Directing attention toward the interpreter (Choice C) is not as crucial as understanding the facility's policy on interpreter use.

4. A nurse is teaching a client about self-administration of enoxaparin. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: The correct instruction for self-administration of enoxaparin is to inject it into the fat tissue of the abdomen for proper absorption. Choice A is incorrect as enoxaparin should not be injected into the muscle. Choice B is unnecessary for enoxaparin administration. Choice C is incorrect as rubbing the injection site after administering the medication is not recommended.

5. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following laboratory values indicates the TPN is effective?

Correct answer: D

Rationale: The correct answer is D. A blood glucose level of 110 mg/dL indicates that the TPN is effective in maintaining normal glucose levels. Hemoglobin level (choice B) is related to anemia and not directly indicative of TPN effectiveness. Albumin level (choice A) is a marker of nutritional status over a longer term and may not reflect immediate TPN effectiveness. White blood cell count (choice C) is related to infection or inflammation and is not a direct indicator of TPN effectiveness.

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