Nursing Elites

1. A 17-year-old adolescent reports flu-like symptoms and is brought to the emergency room. What intervention should the nurse implement first?

• A. Assess the client's temperature.
• B. Place a mask on the client.
• C. Obtain a chest X-ray per protocol.
• D. Determine the client's blood pressure.

Correct answer: B

Rationale: The correct answer is to place a mask on the client. This intervention is crucial in preventing the spread of infections like the flu, especially in a healthcare setting where the risk of transmission is high. Assessing the client's temperature (Choice A) can be important but is not the priority in this situation. Obtaining a chest X-ray (Choice C) and determining the client's blood pressure (Choice D) are not the immediate interventions needed for a 17-year-old reporting flu-like symptoms.

2. Prior to surgery, written consent must be obtained. What is the nurse's legal responsibility with regard to obtaining written consent?

• A. Witness the consent and sign the form as a witness
• B. Inform the client of alternatives to the procedure
• C. Explain the procedure in detail to the client
• D. Determine that the surgical consent form has been signed and is included in the client's record

Correct answer: D

Rationale: The nurse's legal responsibility is to ensure that informed consent has been obtained by verifying that the client has signed the form and that it is included in the record. Witnessing the consent and signing as a witness is not the nurse's role, as this is typically done by a neutral party. Informing the client of alternatives to the procedure and explaining the procedure in detail are responsibilities of the healthcare provider performing the surgery, not the nurse.

3. Before administering digoxin to a client with heart failure, what is the most important assessment for the nurse to perform?

• A. Check the client's blood pressure
• B. Monitor the client's heart rate
• C. Assess the client's respiratory rate
• D. Review the client's potassium level

Correct answer: B

Rationale: The correct answer is to monitor the client's heart rate. Digoxin slows the heart rate, so it is crucial to assess the heart rate before administering the medication. If the heart rate is below 60 beats per minute, the dose should be held, and the healthcare provider should be notified. Checking the blood pressure (Choice A) is important but not as crucial as monitoring the heart rate in this case. Assessing the respiratory rate (Choice C) is not directly related to the action of digoxin. Reviewing the client's potassium level (Choice D) is important for clients taking digoxin due to the risk of hypokalemia, but assessing the heart rate takes priority.

4. A client is receiving continuous intravenous heparin for a deep vein thrombosis. Which laboratory result should the nurse monitor to ensure therapeutic heparin levels?

• A. International normalized ratio (INR)
• B. Activated partial thromboplastin time (aPTT)
• C. Hemoglobin
• D. Platelet count

Correct answer: B

Rationale: The activated partial thromboplastin time (aPTT) is the most accurate measure of heparin's therapeutic effect. Heparin increases the time it takes for blood to clot, and the aPTT helps determine whether the dose is within the desired range for anticoagulation therapy. Monitoring the INR, hemoglobin, or platelet count is not specific to assessing therapeutic heparin levels and may not reflect the anticoagulant effect of heparin.

5. The nurse is caring for a client with chronic heart failure who is receiving digoxin therapy. The nurse reviews the client's lab results and notes that the serum potassium level is 3.0 mEq/L. What action should the nurse take next?

• A. Administer a potassium supplement
• B. Notify the healthcare provider
• C. Hold the next dose of digoxin
• D. Increase dietary potassium intake

Correct answer: C

Rationale: In clients receiving digoxin therapy, low potassium levels can increase the risk of digoxin toxicity. Therefore, when the nurse notes a serum potassium level of 3.0 mEq/L, it is crucial to hold the next dose of digoxin. Notifying the healthcare provider is essential to ensure appropriate interventions, such as potassium supplementation, can be implemented. Administering a potassium supplement without healthcare provider guidance may lead to rapid potassium level changes and potential adverse effects. Increasing dietary potassium intake alone may not promptly address the low serum potassium level in this acute situation.

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