Nursing Elites

1. Which electrolyte imbalance is most concerning in a patient taking digoxin?

• A. Monitor potassium levels
• B. Monitor calcium levels
• C. Monitor sodium levels
• D. Monitor magnesium levels

Correct answer: A

Rationale: The correct answer is to monitor potassium levels. Patients taking digoxin are at risk of developing toxicity due to hypokalemia. Low potassium levels can potentiate the toxic effects of digoxin on the heart, leading to serious arrhythmias. Monitoring calcium levels (Choice B) is not the primary concern in patients taking digoxin. While calcium levels play a role in cardiac function, hypocalcemia is not directly associated with digoxin toxicity. Monitoring sodium levels (Choice C) is important for other conditions but is not the primary concern in a patient taking digoxin. Monitoring magnesium levels (Choice D) is also essential, but hypomagnesemia is not as directly linked to digoxin toxicity as hypokalemia.

2. What is the best intervention for a patient with constipation?

• A. Administer a stool softener
• B. Encourage fluid intake
• C. Provide a high-fiber diet
• D. Administer a laxative

Correct answer: B

Rationale: Encouraging fluid intake is the best intervention for a patient with constipation. Fluids help soften stools, making them easier to pass. While stool softeners and laxatives can also help with constipation, they are more of a short-term solution and may not address the root cause. A high-fiber diet is beneficial for preventing constipation in the long run, but in the immediate situation of constipation, fluid intake is key.

3. A nurse is caring for a client who is 1 hour postpartum. Which of the following findings should the nurse report to the provider?

• A. Fundus firm and at the umbilicus.
• B. Heart rate 80/min.
• C. Blood pressure 130/78 mm Hg.
• D. A constant trickle of bright red blood from the vagina.

Correct answer: D

Rationale: After childbirth, it is normal for the fundus to be firm and at the level of the umbilicus, heart rate to be around 80/min, and blood pressure to be slightly elevated. However, a constant trickle of bright red blood from the vagina is concerning as it could indicate postpartum hemorrhage. This finding should be reported promptly to the healthcare provider for further evaluation and intervention. Choices A, B, and C are within expected postpartum parameters and do not indicate an immediate need for intervention.

4. A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

• A. Insert a tongue depressor into the client's mouth.
• B. Restrain the client's arms and legs.
• C. Turn the client onto their side.
• D. Place the client in a prone position.

Correct answer: C

Rationale: During a tonic-clonic seizure, the nurse should turn the client onto their side. This action helps maintain an open airway by allowing saliva or any vomitus to drain out of the mouth, reducing the risk of aspiration. Inserting a tongue depressor (choice A) is incorrect as it can cause injury to the client's mouth and is not recommended during a seizure. Restraining the client's arms and legs (choice B) can lead to physical harm and should be avoided. Placing the client in a prone position (choice D) is dangerous as it can obstruct the airway and hinder breathing, which is not suitable for a client experiencing a seizure.

5. A nurse is caring for a client who is postpartum and reports perineal pain. Which intervention should the nurse implement?

• A. Administer analgesics as prescribed.
• B. Apply a warm compress to the perineum.
• C. Encourage the client to ambulate frequently.
• D. Position the client with the head elevated.

Correct answer: A

Rationale: Administering analgesics as prescribed is the appropriate intervention for managing perineal pain in a postpartum client. Analgesics help to alleviate discomfort and promote the client's recovery. Applying a warm compress (choice B) may provide some relief, but it does not address the pain as effectively as analgesics. Encouraging ambulation (choice C) and positioning the client with the head elevated (choice D) are not directly related to addressing perineal pain.

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