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. A healthcare professional is caring for a group of clients on a medical-surgical unit. Which of the following clients is at increased risk for body-image disturbances?

• A. A client who had a laparoscopic appendectomy
• B. A client who had a mastectomy
• C. A client who had a left above-the-knee amputation
• D. A client who had a cardiac catheterization

Correct answer: C

Rationale: Clients who have undergone significant visible body changes, like amputation, are at increased risk for body-image disturbances. Amputation can have a profound impact on self-image and body perception due to the visible structural alteration. While conditions like laparoscopic appendectomy, mastectomy, and cardiac catheterization may also affect body image, they are less likely to cause significant disturbances compared to visible changes like amputation.

3. During a neurological assessment, a healthcare provider is evaluating a client's balance. Which of the following examinations should the provider use for this purpose?

• A. Romberg test
• B. Deep tendon reflexes
• C. Mini-Mental State Examination
• D. Babinski reflex

Correct answer: A

Rationale: The Romberg test is utilized to assess the client's balance and proprioception by having them stand with their eyes closed. This test helps evaluate sensory ataxia, a condition where an individual's balance is affected due to impaired sensory input. Deep tendon reflexes (Choice B) are assessed by tapping a tendon with a reflex hammer to evaluate the integrity of the spinal cord and peripheral nerves; this is not directly related to balance assessment. The Mini-Mental State Examination (Choice C) is a cognitive screening tool used to assess cognitive impairment or dementia, not balance. The Babinski reflex (Choice D) is elicited by stroking the sole of the foot to assess neurologic function, particularly in the corticospinal tract, and is not specific to balance evaluation.

4. A client asks a nurse about their Snellen eye test results. The client's visual acuity is 20/30. Which of the following responses should the nurse make?

• A. “Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet.”
• B. “Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet.”
• C. “Your eyes see at 30 feet what visually unimpaired eyes see at 20 feet.”
• D. “Your left eye can see the chart clearly at 20 feet, and your right eye can see the chart clearly at 30 feet.”

Correct answer: A

Rationale: The correct answer is A: 'Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet.' In the Snellen eye test, a visual acuity of 20/30 means that the client sees at 20 feet what a person with normal vision sees at 30 feet. This indicates that the client's vision is slightly worse than average. Choice B is incorrect as it incorrectly describes the visual acuity of each eye individually, rather than the combined visual acuity. Choice C is incorrect as it misinterprets the meaning of the Snellen eye test results by reversing the values. Choice D is incorrect as it inaccurately describes the visual acuity of the client's eyes, attributing different visual acuities to each eye instead of a combined measurement as indicated by 20/30.

5. A client is scheduled for a bronchoscopy. After the nurse explains the procedure, which statement by the client indicates a need for further teaching?

• A. I'm glad I don’t have to lie still for this procedure.
• B. I will have a local anesthetic to help with discomfort.
• C. I hope I get some medicine to relax me.
• D. I can't eat or drink for 6 hours before the procedure.

Correct answer: A

Rationale: The correct answer is A because the client's statement indicates a misunderstanding about the need to lie still during the bronchoscopy procedure. The client actually needs to remain still for the procedure to ensure its accuracy and safety. Choices B, C, and D demonstrate an understanding of the procedure by acknowledging the local anesthetic for discomfort, the possibility of receiving medicine for relaxation, and the requirement to fast before the procedure, respectively.

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