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 nursing intervention for a patient experiencing fluid overload?

• A. Administer diuretics
• B. Administer IV fluids
• C. Provide oral fluids
• D. Provide chest physiotherapy

Correct answer: A

Rationale: The best nursing intervention for a patient experiencing fluid overload is to administer diuretics. Diuretics help the body to remove excess fluid by increasing urine output. This intervention is crucial in managing fluid overload. Administering IV fluids (Choice B) would worsen the condition by adding more fluids to the already overloaded system. Providing oral fluids (Choice C) is not appropriate as it would further contribute to the fluid overload. Chest physiotherapy (Choice D) is not indicated in the treatment of fluid overload and would not address the underlying issue of excess fluid accumulation.

3. A nurse is providing care for a client who is in the advanced stage of amyotrophic lateral sclerosis (ALS). Which of the following referrals is the nurse's priority?

• A. Psychologist
• B. Social worker
• C. Occupational therapist
• D. Speech-language pathologist

Correct answer: D

Rationale: In the advanced stage of ALS, clients often experience swallowing difficulties, known as dysphagia. A speech-language pathologist specializes in assessing and managing these swallowing problems, making them the nurse's priority referral in this case. A psychologist primarily focuses on mental health and emotional well-being, which may not be the most critical issue at this stage. Social workers assist with social support and resources, while occupational therapists help with activities of daily living and mobility, which are important but not the priority when dysphagia is a concern.

4. A patient is 1 day postoperative following a total knee arthroplasty. Which of the following actions should the nurse take?

• A. Administer aspirin for pain management.
• B. Keep the affected leg in a dependent position.
• C. Flex the affected knee for 2 to 3 minutes every hour.
• D. Apply ice packs to the affected knee.

Correct answer: D

Rationale: The correct action for a client 1 day postoperative following a total knee arthroplasty is to apply ice packs to the affected knee. Ice packs help reduce swelling and pain in such clients. Administering aspirin is contraindicated due to the risk of bleeding postoperatively. Keeping the affected leg in a dependent position can impair circulation and increase the risk of complications. Flexing the affected knee for extended periods can strain the surgical site and hinder the healing process.

5. A nurse is preparing to administer an enema to a client. Which of the following actions should the nurse take?

• A. Place the client in a high-Fowler's position
• B. Assist the client to the left Sims' position
• C. Insert the enema tubing 2.5 cm (1 in) into the rectum
• D. Lubricate the tip of the enema tubing with petroleum jelly

Correct answer: B

Rationale: The correct answer is to assist the client to the left Sims' position when administering an enema. This position helps facilitate the flow of the enema solution into the rectum. Placing the client in a high-Fowler's position (Choice A) is not ideal for administering an enema. Inserting the enema tubing 2.5 cm (1 in) into the rectum (Choice C) is incorrect as it should be inserted 7.5-10 cm (3-4 in) for an adult. Lubricating the tip of the enema tubing with petroleum jelly (Choice D) is a correct step to ease insertion but is not the most critical action among the choices provided.

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