Nursing Elites

1. Which lab value should be monitored in a patient on digoxin?

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

Correct answer: C

Rationale: The correct answer is to monitor digoxin levels in a patient on digoxin. Digoxin is a medication commonly used to treat heart conditions, and monitoring its levels in the blood is crucial to ensure that the patient is within the therapeutic range and to prevent toxicity. Monitoring potassium levels (Choice A) is important due to the potential of digoxin-induced hypokalemia, but the primary focus should be on monitoring digoxin levels. Monitoring calcium levels (Choice B) and sodium levels (Choice D) are not directly related to digoxin therapy and are not the primary lab values of concern when administering digoxin.

2. A nurse is preparing to administer an intermittent enteral feeding to a client who has an NG tube. Which of the following actions should the nurse take?

• A. Heat the feeding to 105°F (40.6°C).
• B. Elevate the head of the bed to 45 degrees.
• C. Flush the tube with 0.9% sodium chloride.
• D. Verify the pH of the gastric aspirate.

Correct answer: D

Rationale: Verifying the pH of the gastric aspirate is the correct action to take before administering an intermittent enteral feeding through an NG tube. This step ensures proper tube placement in the stomach, as the gastric aspirate should have an acidic pH (usually below 5). Heating the feeding solution, elevating the head of the bed, or flushing the tube with saline are not directly related to verifying tube placement and are not the immediate actions needed before administering the feeding.

3. What is the primary nursing action for a patient with confusion post-surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Monitor vital signs
• D. Check oxygen saturation

Correct answer: A

Rationale: Administering oxygen is the primary nursing action for a patient with confusion post-surgery because it helps address any potential hypoxia that may be contributing to the patient's confusion. While repositioning the patient, monitoring vital signs, and checking oxygen saturation are important nursing interventions, administering oxygen takes precedence in ensuring adequate oxygenation levels, which is crucial in managing post-surgery confusion.

4. A nurse is caring for a client who has a prescription for digoxin. Which of the following laboratory values should the nurse monitor to identify an adverse effect of this medication?

• A. Potassium 3.5 mEq/L
• B. Sodium 140 mEq/L
• C. Calcium 9.5 mg/dL
• D. Magnesium 2.0 mEq/L

Correct answer: A

Rationale: The correct answer is A: Potassium 3.5 mEq/L. Digoxin can cause hypokalemia as an adverse effect. Monitoring potassium levels is crucial because low potassium levels can increase the risk of digoxin toxicity. Choices B, C, and D are incorrect as they are not directly associated with potential adverse effects of digoxin. Sodium levels are not typically affected by digoxin, calcium levels are not a primary concern with digoxin therapy, and magnesium levels are not the most important to monitor for digoxin adverse effects.

5. A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

• A. Place the cap from the solution sterile side up on a clean surface.
• B. Open the outermost flap of the sterile kit away from the body.
• C. Place the sterile dressing within 1.25 cm of the edge of the sterile field.
• D. Set up the sterile field 5 cm below waist level.

Correct answer: B

Rationale: When setting up a sterile field for a dressing change, the nurse should open the outermost flap of the sterile kit away from the body. This action helps maintain the sterility of the field by minimizing the risk of contamination. Option A is incorrect because the cap from the solution should be placed sterile side down to prevent contamination. Option C is incorrect because the sterile dressing should be placed at least 1.25 cm away from the edge of the sterile field to maintain its sterility. Option D is incorrect because the sterile field should be set up above waist level to prevent potential contamination from reaching the field.

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