Nursing Elites

1. A nurse is providing teaching to a client who has been prescribed digoxin for heart failure. Which of the following instructions should the nurse include?

• A. Take this medication with meals.
• B. Check your pulse before taking this medication.
• C. Take this medication with an antacid to reduce stomach upset.
• D. Increase your potassium intake while taking this medication.

Correct answer: B

Rationale: The correct answer is B: 'Check your pulse before taking this medication.' When a patient is prescribed digoxin, it is crucial to monitor their pulse rate because digoxin can cause bradycardia (slow heart rate) as a side effect. In contrast, choices A, C, and D are incorrect. Taking digoxin with meals is not necessary; it should be taken consistently at the same time every day. Taking digoxin with an antacid is not recommended as it can interfere with the absorption of the medication. While digoxin can cause hypokalemia (low potassium levels), patients should not increase their potassium intake without healthcare provider guidance to avoid potential complications.

2. What is the first action to take for a patient experiencing a seizure?

• A. Administer anticonvulsant medication
• B. Protect the patient's head
• C. Insert an oral airway
• D. Restrain the patient

Correct answer: B

Rationale: The first action a nurse should take for a patient experiencing a seizure is to protect the patient's head. This is crucial to prevent head injuries during the seizure. Administering anticonvulsant medication may be necessary but is not the first action. Inserting an oral airway may cause injury as the patient may bite down during a seizure. Restraint is not recommended as it can lead to further harm.

3. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays toxicity. Which of the following actions should the nurse take?

• A. Position the client supine.
• B. Prepare an IV bolus of dextrose 5% in water.
• C. Administer methylergonovine IM.
• D. Administer calcium gluconate IV.

Correct answer: D

Rationale: Administering calcium gluconate IV is the correct action when a client displays toxicity from magnesium sulfate. Calcium gluconate is used as the antidote for magnesium sulfate toxicity as it counteracts the effects. Positioning the client supine (Choice A) is not the immediate action needed. Administering dextrose 5% in water (Choice B) is not indicated for magnesium sulfate toxicity. Administering methylergonovine IM (Choice C) is used in postpartum hemorrhage, not for magnesium sulfate toxicity.

4. A client who is postoperative following hip replacement surgery. Which of the following actions should the nurse take to prevent dislocation of the hip?

• A. Position the client's legs in adduction
• B. Place a pillow between the client's legs when turning
• C. Keep the client in a low Fowler's position
• D. Turn the client onto the affected side

Correct answer: B

Rationale: Placing a pillow between the client's legs when turning is essential to prevent hip dislocation post hip replacement surgery. This action helps maintain proper alignment of the hip joint and prevents adduction, which can lead to dislocation. Positioning the client's legs in adduction (choice A) can increase the risk of hip dislocation. Keeping the client in a low Fowler's position (choice C) or turning the client onto the affected side (choice D) does not directly address hip dislocation prevention.

5. A nurse is teaching a newly licensed nurse about using a portable oxygen system. What instruction should the nurse include?

• A. The oxygen should be kept in a storage room when not in use.
• B. Turn off the oxygen when not in use.
• C. Check the oxygen level regularly using a pulse oximeter.
• D. Never leave the oxygen running when transporting a client.

Correct answer: C

Rationale: The correct answer is to check the oxygen level regularly using a pulse oximeter. This instruction is crucial as it ensures safe and adequate oxygenation for the client. Option A is incorrect as oxygen should not be stored in a storage room but in a well-ventilated area. Option B is not ideal as oxygen should be left on unless otherwise specified by a healthcare provider. Option D is also important but not directly related to the primary instruction of monitoring oxygen levels.

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