Nursing Elites

1. A client is receiving discharge teaching about a new prescription for digoxin (Lanoxin). Which statement by the client indicates a need for further teaching?

• A. I should avoid foods high in potassium while taking this medication.
• B. I will check my pulse before taking the medication.
• C. I should avoid taking antacids simultaneously with this medication.
• D. I will take the medication at the same time every day.

Correct answer: A

Rationale: The correct answer is A because clients taking digoxin should avoid foods high in potassium. High potassium levels can potentiate the effects of digoxin, leading to toxicity. Choices B, C, and D are correct statements regarding digoxin administration. Checking the pulse before taking the medication helps monitor for signs of digoxin toxicity. Avoiding taking antacids simultaneously prevents interactions that may reduce digoxin absorption. Taking the medication at the same time every day helps maintain a consistent blood level, ensuring optimal therapeutic effects.

2. The healthcare provider is monitoring a client in active labor. Which pattern on the fetal heart monitor requires immediate intervention?

• A. Early decelerations
• B. Late decelerations
• C. Accelerations
• D. Moderate variability

Correct answer: B

Rationale: Late decelerations are concerning as they indicate uteroplacental insufficiency, potentially resulting in fetal hypoxia. Immediate intervention is necessary to address the underlying cause and ensure fetal well-being. Early decelerations are typically benign and associated with head compression during contractions. Accelerations are reassuring and indicate fetal well-being. Moderate variability is a normal finding and indicates a healthy autonomic nervous system response. Therefore, late decelerations (Choice B) require immediate attention, while the other patterns are generally considered normal or benign during labor.

3. During an abdominal examination, a nurse in a provider’s office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect?

• A. Fat
• B. Fluid
• C. Flatus
• D. Hernias

Correct answer: D

Rationale: The correct answer is 'Hernias.' Abdominal distention with a midline protrusion, taut skin, and no involvement of the flanks is characteristic of hernias. Hernias are caused by a weakness in the abdominal wall, allowing organs or tissues to protrude through. Fluid accumulation (ascites) typically presents with a more generalized distention, while fat accumulation may cause more diffuse distension rather than a focal midline protrusion. Flatus, or gas, would not typically present with a visible midline protrusion and taut skin like hernias.

4. The nurse is caring for an older adult patient who has been diagnosed with a stroke. Which intervention will the nurse add to the care plan?

• A. Encourage the patient to perform as many self-care activities as possible.
• B. Provide assistance with a bed bath to promote patient comfort.
• C. Coordinate with physical therapy for gait training.
• D. Instruct the patient to remain on bed rest to prevent fatigue.

Correct answer: A

Rationale: The correct answer is A: Encourage the patient to perform as many self-care activities as possible. For a patient who has had a stroke, promoting independence and engaging in self-care activities help maintain mobility and foster a sense of autonomy. Choices B, C, and D are incorrect because providing assistance with a bed bath, coordinating with physical therapy for gait training, or advising bed rest without indications may not be the best interventions for promoting optimal recovery and independence in a stroke patient.

5. Prior to a client being transported for a chest x-ray, what should a healthcare professional do first?

• A. Identify the client using two identifiers
• B. Confirm the client's fasting status
• C. Check the client's allergies to contrast media
• D. Explain the procedure to the client

Correct answer: A

Rationale: Identifying the client using two identifiers is the crucial first step to ensure correct patient identification before any procedure. This process helps prevent errors and ensures that the right procedure is performed on the right patient. Confirming the client's identity is the top priority before addressing other aspects such as fasting status, allergies, or explaining the procedure. While confirming fasting status and checking for allergies are important, they are secondary to confirming the client's identity. Explaining the procedure to the client is also essential but should occur after ensuring proper identification.

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