Nursing Elites

1. A nurse is preparing to administer a dose of digoxin (Lanoxin) to a client with heart failure. Which assessment finding requires immediate intervention?

• A. Apical pulse of 58 beats per minute
• B. Blood pressure of 110/70 mmHg
• C. Presence of a new murmur
• D. Respiratory rate of 18 breaths per minute

Correct answer: A

Rationale: An apical pulse of 58 beats per minute is concerning when administering digoxin because digoxin can further lower the heart rate, leading to bradycardia or heart block. Immediate intervention is required to prevent potential complications. A blood pressure of 110/70 mmHg is within normal range and does not require immediate intervention in this context. The presence of a new murmur may indicate valvular issues but does not directly relate to the administration of digoxin. A respiratory rate of 18 breaths per minute is also within normal limits and is not a priority concern when administering digoxin.

2. A client with chronic kidney disease (CKD) is scheduled for a hemodialysis session. Which laboratory value should the nurse monitor closely?

• A. Serum potassium
• B. Serum creatinine
• C. Serum sodium
• D. Serum chloride

Correct answer: C

Rationale: The correct answer is C: Serum sodium. In a client with chronic kidney disease (CKD) scheduled for hemodialysis, monitoring serum sodium levels closely is essential. Hemodialysis can cause rapid shifts in sodium levels, leading to electrolyte imbalances. While serum potassium (choice A) is important to monitor in CKD, it is not the most crucial before hemodialysis. Serum creatinine (choice B) is an indicator of kidney function but is not the most immediate concern before hemodialysis. Serum chloride (choice D) is not typically the primary electrolyte of concern in CKD patients before hemodialysis.

3. A client with chronic heart failure is receiving furosemide (Lasix). Which assessment finding requires immediate intervention?

• A. Heart rate of 60 beats per minute
• B. Blood pressure of 110/70 mmHg
• C. Crackles in the lungs
• D. Peripheral edema

Correct answer: C

Rationale: In a client with chronic heart failure receiving furosemide, crackles in the lungs indicate pulmonary congestion, requiring immediate intervention. This finding suggests fluid accumulation in the lungs, impairing oxygen exchange and potentially leading to respiratory distress. Monitoring and managing pulmonary congestion promptly are crucial to prevent worsening heart failure and respiratory compromise. The other options, while important to assess in a client with heart failure, do not indicate an immediate need for intervention like crackles in the lungs do. A heart rate of 60 beats per minute may be within the normal range for some individuals, a blood pressure of 110/70 mmHg is relatively stable, and peripheral edema is a common manifestation of heart failure that should be monitored but does not require immediate intervention compared to pulmonary congestion.

4. A client with a history of atrial fibrillation is receiving warfarin (Coumadin). Which assessment finding is most concerning?

• A. INR of 3.5
• B. Prothrombin time (PT) of 15 seconds
• C. Headache
• D. Blood pressure of 140/90 mmHg

Correct answer: C

Rationale: The correct answer is C. A headache in a client with a history of atrial fibrillation receiving warfarin (Coumadin) is concerning as it may indicate bleeding, which requires immediate assessment and intervention. Headaches can be a symptom of increased intracranial pressure due to bleeding, especially in patients on anticoagulants. Options A and B are within acceptable ranges for a client on warfarin therapy, indicating that the medication is effectively managing the clotting times. Option D, a blood pressure of 140/90 mmHg, while elevated, is not directly related to the client's condition of atrial fibrillation and warfarin therapy.

5. A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which laboratory value is most concerning?

• A. Serum glucose of 300 mg/dl
• B. Serum bicarbonate of 18 mEq/L
• C. Serum potassium of 5.5 mEq/L
• D. Serum sodium of 135 mEq/L

Correct answer: C

Rationale: A serum potassium level of 5.5 mEq/L is concerning in a client with DKA as it may indicate worsening hyperkalemia, requiring immediate intervention. Elevated serum potassium levels can lead to life-threatening cardiac arrhythmias. While elevated glucose and low bicarbonate are characteristic of DKA, hyperkalemia poses a higher immediate risk. Serum sodium within the normal range is not typically a primary concern in DKA.

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