Nursing Elites

1. A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following client statements indicates an understanding of the teaching?

• A. I should weigh myself every morning.
• B. I should drink 2 liters of water each day.
• C. I should avoid all physical activity.
• D. I should take an extra dose of diuretic if I gain 2 pounds in a day.

Correct answer: A

Rationale: The corrected answer is A. Weighing daily is crucial for clients with heart failure to monitor fluid status since sudden weight gain can indicate fluid retention. Choice B is incorrect because excessive water intake can worsen fluid retention in heart failure. Choice C is incorrect as some physical activity is encouraged for heart failure clients, tailored to their condition. Choice D is incorrect as adjusting medication doses should always be done under healthcare provider guidance rather than self-administration.

2. What is the most important nursing action for a patient experiencing a deep vein thrombosis (DVT)?

• A. Administer anticoagulants
• B. Encourage ambulation
• C. Apply compression stockings
• D. Monitor oxygen saturation

Correct answer: A

Rationale: Administering anticoagulants is the most crucial nursing action for a patient experiencing a deep vein thrombosis (DVT). Anticoagulants help prevent further clot formation and reduce the risk of complications such as pulmonary embolism. Encouraging ambulation, applying compression stockings, and monitoring oxygen saturation are important interventions in managing DVT, but administering anticoagulants takes priority as it directly targets the clotting process and prevents clot progression.

3. A nurse is caring for a client who has acute pancreatitis. Which of the following laboratory findings should the nurse expect to be elevated?

• A. Hemoglobin
• B. Bilirubin
• C. Amylase
• D. Creatinine

Correct answer: C

Rationale: The correct answer is C: Amylase. Amylase levels are elevated in clients with acute pancreatitis due to inflammation of the pancreas. Elevated hemoglobin (choice A) is not typically associated with acute pancreatitis. Bilirubin (choice B) may be elevated in conditions affecting the liver, not specifically in acute pancreatitis. Creatinine (choice D) is a marker of kidney function and is not directly related to acute pancreatitis.

4. A nurse is caring for a client who is receiving continuous cardiac monitoring. The client's heart rate is 69/min, and the PR interval is 0.24 seconds. What cardiac rhythm should the nurse interpret this finding as?

• A. First-degree AV block.
• B. Premature ventricular contraction.
• C. Sinus bradycardia.
• D. Atrial fibrillation.

Correct answer: A

Rationale: The correct answer is A: First-degree AV block. A PR interval of 0.24 seconds indicates a prolonged PR interval, which is characteristic of first-degree AV block. This rhythm is considered benign and often does not require treatment. Choice B, premature ventricular contraction, is characterized by early, abnormal ventricular contractions and would not be indicated by the findings provided. Choice C, sinus bradycardia, would present with a normal PR interval but a heart rate less than 60 beats per minute. Choice D, atrial fibrillation, is characterized by an irregularly irregular rhythm with no identifiable P waves, which does not align with the findings of a prolonged PR interval in this scenario.

5. A nurse is providing teaching about digoxin administration to the parents of a toddler with heart failure. Which of the following statements should the nurse include?

• A. Limit your child's potassium intake while taking this medication.
• B. You can mix the medication with a half-cup of your child's favorite juice.
• C. Do not repeat the dose if your child vomits within one hour after taking the medication.
• D. Have your child drink a small glass of water after swallowing the medication.

Correct answer: D

Rationale: The correct statement to include in the teaching about digoxin administration is to have the child drink a small glass of water after swallowing the medication. Water helps flush down the medication, preventing irritation in the esophagus. Choice A is incorrect because digoxin may interact with potassium levels, but strict restriction is not necessary. Choice B is incorrect as medications should not be mixed with juices unless specified by the healthcare provider due to possible interactions. Choice C is incorrect because if a child vomits after taking digoxin, the dose should not be repeated to avoid double dosing.

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