Nursing Elites

1. 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.

2. What is the most important nursing action for a patient presenting with confusion after surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Administer IV fluids
• D. Perform a neurological assessment

Correct answer: A

Rationale: Administering oxygen is crucial for a patient presenting with confusion after surgery because it helps alleviate potential hypoxia, which can be a common cause of confusion in the postoperative period. While repositioning the patient, administering IV fluids, and performing a neurological assessment are important nursing interventions in certain situations, addressing hypoxia by administering oxygen takes priority in this case to ensure an adequate oxygen supply to the brain and other vital organs.

3. What is the primary nursing action for a patient with confusion post-surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Monitor vital signs
• D. Check oxygen saturation

Correct answer: A

Rationale: Administering oxygen is the primary nursing action for a patient with confusion post-surgery because it helps address any potential hypoxia that may be contributing to the patient's confusion. While repositioning the patient, monitoring vital signs, and checking oxygen saturation are important nursing interventions, administering oxygen takes precedence in ensuring adequate oxygenation levels, which is crucial in managing post-surgery confusion.

4. How should signs of dehydration in an elderly patient be assessed?

• A. Monitor skin turgor
• B. Check for dry mucous membranes
• C. Monitor for sunken eyes
• D. Check capillary refill

Correct answer: A

Rationale: Corrected Rationale: Monitoring skin turgor is a reliable method to assess dehydration in elderly patients. Skin turgor refers to the skin's elasticity or the skin's ability to return to its normal position after being pinched. In dehydration, the skin loses its elasticity, becoming less flexible and slower to return to its original state. Checking for dry mucous membranes (Choice B), monitoring for sunken eyes (Choice C), and checking capillary refill (Choice D) are all relevant assessments in dehydration but are not as specific or sensitive as monitoring skin turgor. Dry mucous membranes and sunken eyes are indicators of dehydration, while capillary refill is more related to circulatory status and less specific to dehydration.

5. What is the priority nursing assessment for a patient with chronic kidney disease?

• A. Monitor serum creatinine
• B. Monitor blood pressure
• C. Monitor urine output
• D. Monitor potassium levels

Correct answer: A

Rationale: The correct answer is to monitor serum creatinine. In patients with chronic kidney disease, monitoring serum creatinine is crucial as it reflects kidney function. This assessment helps healthcare providers in evaluating the progression of the disease and adjusting treatment plans accordingly. Monitoring blood pressure (choice B) is essential in managing chronic kidney disease, but monitoring serum creatinine takes precedence. Monitoring urine output (choice C) and potassium levels (choice D) are also important aspects of managing chronic kidney disease, but they are not the priority assessment compared to monitoring serum creatinine.

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