Nursing Elites

1. A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following findings should indicate to the nurse that the medication has been effective?

• A. Cardiac workload decreases
• B. Blood pressure increases
• C. Respiratory rate increases
• D. Temperature decreases

Correct answer: A

Rationale: The correct answer is A: Cardiac workload decreases. Digoxin helps reduce cardiac workload in clients with heart failure, improving symptoms. This reduction in workload indicates that the medication is effective. Choice B, blood pressure increases, is incorrect because digoxin typically does not directly affect blood pressure. Choice C, respiratory rate increases, is incorrect as an increased respiratory rate is not a typical indicator of digoxin effectiveness. Choice D, temperature decreases, is also incorrect as digoxin does not typically affect body temperature.

2. A nurse is reviewing the plan of care for a client who is postoperative following a hip replacement. Which of the following interventions should the nurse implement to prevent venous thromboembolism?

• A. Instruct the client to perform ankle pumps
• B. Administer anticoagulant therapy as prescribed
• C. Maintain the client in a prone position
• D. Encourage the client to ambulate as tolerated

Correct answer: B

Rationale: The correct intervention to prevent venous thromboembolism in a postoperative client following hip replacement is to administer anticoagulant therapy as prescribed. Anticoagulants help prevent blood clots from forming. Instructing the client to perform ankle pumps helps prevent blood clots by promoting circulation. Maintaining the client in a prone position can increase the risk of venous stasis and thrombus formation. Encouraging the client to ambulate as tolerated also helps prevent venous thromboembolism by promoting blood flow and preventing stasis.

3. A nurse is reviewing the plan of care for a client who is receiving oxygen therapy. Which of the following interventions should the nurse include to prevent complications?

• A. Check the client's oxygen saturation every 2 hours
• B. Provide humidified oxygen
• C. Instruct the client to perform deep breathing exercises
• D. Use an oxygen mask for delivery

Correct answer: B

Rationale: The correct answer is B: Provide humidified oxygen. Providing humidified oxygen helps prevent dryness and irritation of the respiratory tract during oxygen therapy. This intervention is crucial in preventing complications such as mucous membrane dryness and potential damage to the airways. Checking the client's oxygen saturation every 2 hours (choice A) is essential for monitoring the client's response to therapy but does not directly prevent complications. Instructing the client to perform deep breathing exercises (choice C) is beneficial for respiratory function but does not directly address preventing complications related to oxygen therapy. Using an oxygen mask for delivery (choice D) is a common method of administering oxygen but does not specifically focus on preventing complications like dryness and irritation.

4. How should a healthcare professional assess a patient for potential deep vein thrombosis (DVT)?

• A. Assess for unilateral leg swelling
• B. Encourage early mobilization
• C. Check for calf tenderness
• D. Observe for redness and warmth

Correct answer: A

Rationale: To assess a patient for potential deep vein thrombosis (DVT), healthcare professionals should look for unilateral leg swelling. This is a classic sign of DVT. While encouraging early mobilization is generally beneficial for preventing DVT, it is not a method of assessment. Checking for calf tenderness is also relevant but not as specific as unilateral leg swelling. Observing for redness and warmth can be signs of inflammation but are not as specific to DVT as unilateral leg swelling.

5. A nurse is caring for a client who is scheduled for a bronchoscopy. Which of the following findings should the nurse report to the provider?

• A. The client is anxious about the procedure.
• B. The client has not eaten for 8 hours.
• C. The client has a reported allergy to shellfish.
• D. The client has a platelet count of 100,000/mm³.

Correct answer: D

Rationale: The correct answer is D. A platelet count of 100,000/mm³ is low and increases the risk of bleeding during the bronchoscopy. This finding should be reported to the provider for further evaluation and possible intervention. Choices A, B, and C are not as critical in this situation. Anxiety about the procedure is common and can be managed with appropriate interventions. Not eating for 8 hours is a standard pre-procedure requirement to prevent aspiration during sedation. A reported allergy to shellfish is important to note but is not directly related to the risk of complications during a bronchoscopy.

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