Nursing Elites

1. The healthcare provider is preparing to administer digoxin (Lanoxin) to a client. Which assessment finding should the healthcare provider report before administering the medication?

• A. Apical pulse of 58 beats per minute.
• B. Serum potassium level of 3.0 mEq/L.
• C. Blood pressure of 140/90 mm Hg.
• D. Client reports seeing halos around lights.

Correct answer: D

Rationale: Seeing halos around lights is a classic symptom of digoxin toxicity, known as visual disturbances. This finding indicates an adverse effect of digoxin and should be reported immediately to the healthcare provider. Monitoring for visual changes is crucial as it can progress to more severe toxicity, leading to life-threatening dysrhythmias or other complications. Apical pulse, serum potassium level, and blood pressure are important assessments when administering digoxin, but the presence of visual disturbances, such as seeing halos around lights, takes precedence due to its direct association with digoxin toxicity. Changes in these other parameters should also be noted and addressed, but they are not the priority when compared to a symptom directly linked to potential toxicity.

2. A community health nurse is helping a group of nursing students plan a tertiary prevention program for a local community clinic that serves a majority Hispanic population. Which service project meets the requirement of a tertiary prevention program and would best serve this population?

• A. teaching clients about recommended immunizations for children
• B. demonstrating foot care to a group of clients who have diabetes
• C. taking blood pressures at a local shopping mall in the community
• D. instructing teens about prevention of sexually transmitted diseases

Correct answer: B

Rationale: The correct answer is B. Tertiary prevention focuses on managing and improving health outcomes for existing conditions, such as diabetes. Demonstrating foot care to clients with diabetes aligns with this level of prevention by helping to prevent complications and promote better health outcomes. Choices A, C, and D do not specifically target existing conditions or chronic diseases, which are the focus of tertiary prevention programs.

3. In conducting a health assessment for a family with a history of cardiovascular disease, which family member should be prioritized for further evaluation and intervention?

• A. a 45-year-old father who smokes and has high cholesterol
• B. a 17-year-old daughter who is overweight and inactive
• C. a 50-year-old mother with a history of hypertension
• D. a 12-year-old son who has a normal weight and is active

Correct answer: A

Rationale: The 45-year-old father who smokes and has high cholesterol is at a higher risk for cardiovascular disease due to multiple risk factors. Smoking and high cholesterol are significant contributors to the development of cardiovascular issues. Prioritizing his evaluation and intervention is crucial to address these modifiable risk factors. The other family members, though they may have risk factors as well, do not present with the same level of immediate risk based on the information provided.

4. A client with a history of atrial fibrillation is receiving warfarin (Coumadin) therapy. Which laboratory result indicates that the therapy is effective?

• A. International normalized ratio (INR) of 1.0.
• B. Prothrombin time (PT) of 12 seconds.
• C. Partial thromboplastin time (PTT) of 60 seconds.
• D. International normalized ratio (INR) of 2.5.

Correct answer: D

Rationale: An International Normalized Ratio (INR) of 2.5 indicates that warfarin therapy is within the therapeutic range for a client with atrial fibrillation. A lower INR (such as 1.0) would suggest subtherapeutic levels, risking blood clots. Prothrombin time (PT) and partial thromboplastin time (PTT) are not specific to monitoring warfarin therapy.

5. The nurse is assessing a client with pneumonia. Which finding requires immediate intervention?

• A. Temperature of 99°F (37.2°C).
• B. Respiratory rate of 20 breaths per minute.
• C. Heart rate of 90 beats per minute.
• D. Fatigue.

Correct answer: C

Rationale: In a client with pneumonia, a heart rate of 90 beats per minute requires immediate intervention. Jugular vein distention indicates increased central venous pressure, suggesting possible complications like heart failure or fluid overload. Monitoring the heart rate closely and addressing any signs of heart failure promptly are crucial. A temperature of 99°F is within normal range and does not require immediate intervention. A respiratory rate of 20 breaths per minute is also normal. Fatigue is a common symptom in pneumonia but does not indicate an immediate need for intervention compared to the critical nature of jugular vein distention.

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