Nursing Elites

1. A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding?

• A. Weak femoral pulses.
• B. Frequent nosebleeds.
• C. Upper extremity hypotension.
• D. Increased intracranial pressure.

Correct answer: A

Rationale: Corrected Rationale: Weak femoral pulses are an expected finding in an infant with coarctation of the aorta. The narrowing of the aorta leads to decreased blood flow to the lower extremities, resulting in weak or absent femoral pulses. Frequent nosebleeds (Choice B) are not typically associated with coarctation of the aorta. Upper extremity hypotension (Choice C) is not a common finding in coarctation of the aorta; instead, blood pressure is usually elevated in the upper extremities. Increased intracranial pressure (Choice D) is not directly related to coarctation of the aorta.

2. A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following findings should the nurse report to the provider?

• A. Potassium 4.0 mEq/L
• B. Calcium 9.5 mg/dL
• C. Heart rate of 60/min
• D. Sodium 140 mEq/L

Correct answer: C

Rationale: The correct answer is C: Heart rate of 60/min. A heart rate of 60/min is borderline bradycardia, which can be a sign of digoxin toxicity. Digoxin can cause bradycardia, so any further decrease in heart rate should be reported promptly to the healthcare provider. Choices A, B, and D are within the normal range and not specifically related to potential digoxin toxicity, so they do not require immediate reporting.

3. A client who is taking phenytoin is being taught about contraceptive options. Which of the following statements should the nurse make?

• A. You should use a backup method of birth control while taking phenytoin.
• B. Phenytoin can decrease the effectiveness of oral contraceptives.
• C. You should stop taking phenytoin while using oral contraceptives.
• D. Phenytoin can increase the effectiveness of oral contraceptives.

Correct answer: B

Rationale: The correct answer is B. Phenytoin can decrease the effectiveness of oral contraceptives, so it is important to inform the client about this interaction. Using an additional form of contraception, such as a backup method, is recommended to ensure adequate protection against pregnancy. Choice A is incorrect because it lacks specificity about the decrease in effectiveness of oral contraceptives caused by phenytoin. Choice C is incorrect as it suggests stopping phenytoin use while using oral contraceptives, which is not the appropriate action. Choice D is incorrect as phenytoin is known to decrease, not increase, the effectiveness of oral contraceptives.

4. A nurse is providing teaching about newborn care to a group of parents. Which of the following instructions should the nurse include?

• A. You should not bathe your newborn every day.
• B. You should avoid covering your newborn with a heavy blanket during naps.
• C. You should expect your newborn's stools to be soft and yellow.
• D. You should keep your newborn's head elevated while they sleep.

Correct answer: D

Rationale: The correct answer is D: 'You should keep your newborn's head elevated while they sleep.' Keeping the newborn's head elevated while sleeping helps prevent conditions like sudden infant death syndrome (SIDS). Choice A is incorrect because newborns do not need to be bathed every day; it is recommended to bathe them 2-3 times a week. Choice B is incorrect as heavy blankets can increase the risk of suffocation for newborns. Choice C is incorrect as newborn stools are typically soft and yellow in color, not firm and light brown.

5. A nurse is reviewing the medical record of a client who has a prescription for spironolactone. Which of the following findings should the nurse report to the provider?

• A. Potassium 5.0 mEq/L
• B. Blood pressure 136/84 mm Hg
• C. Sodium 140 mEq/L
• D. Calcium 9.5 mg/dL

Correct answer: A

Rationale: A potassium level of 5.0 mEq/L is at the upper limit of normal and should be monitored closely in clients taking spironolactone, which is potassium-sparing. Elevated potassium levels can lead to hyperkalemia, especially in individuals on potassium-sparing diuretics like spironolactone. Monitoring and reporting high potassium levels are crucial to prevent potential complications such as cardiac arrhythmias. Blood pressure (choice B), sodium level (choice C), and calcium level (choice D) are not directly related to the use of spironolactone and do not require immediate reporting in this scenario.

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