Nursing Elites

1. A client with a history of atrial fibrillation is taking digoxin (Lanoxin). Which finding should the healthcare provider be notified of immediately?

• A. Heart rate of 52 beats per minute
• B. Blood pressure of 110/70 mmHg
• C. Blood glucose level of 180 mg/dL
• D. Potassium level of 4.0 mEq/L

Correct answer: A

Rationale: A heart rate of 52 beats per minute is a critical finding in a client taking digoxin, as it may indicate digoxin toxicity. Digoxin can cause bradycardia as a side effect, and a heart rate of 52 bpm warrants immediate attention to prevent adverse outcomes. Monitoring and reporting changes in heart rate are crucial in clients on digoxin therapy to prevent serious complications. The other vital signs and laboratory values provided are within normal ranges or not directly associated with digoxin toxicity in this scenario, making them lower priority for immediate reporting.

2. A client with congestive heart failure (CHF) is receiving furosemide (Lasix). Which laboratory value should the LPN monitor closely while the client is taking this medication?

• A. Sodium
• B. Potassium
• C. Calcium
• D. Magnesium

Correct answer: B

Rationale: The LPN should monitor potassium levels closely while the client is taking furosemide (Lasix) due to the medication's potential to cause hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss through increased urine output. Hypokalemia can result in serious complications such as cardiac dysrhythmias. Monitoring sodium levels (choice A) is important but not as critical as monitoring potassium in this context. Calcium (choice C) and magnesium (choice D) levels are not typically affected by furosemide and are not the priority for monitoring in this scenario.

3. A mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. What is the best response by the nurse?

• A. Folic acid should be taken before and after conception.
• B. Multivitamin supplements are recommended during pregnancy.
• C. A well-balanced diet promotes normal fetal development.
• D. Increased dietary iron improves the health of mother and fetus.

Correct answer: A

Rationale: The correct answer is A: 'Folic acid should be taken before and after conception.' Folic acid supplementation before and during early pregnancy has been shown to significantly reduce the risk of neural tube defects. Choice B is incorrect because while multivitamin supplements are beneficial during pregnancy, the specific focus for preventing neural tube defects is on folic acid. Choice C is a general statement about a well-balanced diet and does not specifically address neural tube defects. Choice D is incorrect as it focuses on dietary iron, which is important for overall health but not specifically proven to prevent neural tube defects.

4. A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the LPN/LVN to implement?

• A. Obtain the pre-transfusion hemoglobin level.
• B. Prime the tubing and set up the blood pump.
• C. Monitor vital signs every 15 minutes for the first hour.
• D. Ensure the accuracy of the blood type match.

Correct answer: D

Rationale: Ensuring the accuracy of the blood type match is crucial to prevent transfusion reactions. The LPN/LVN must prioritize this step to avoid adverse outcomes. Obtaining the pre-transfusion hemoglobin level (Option A) is important but not as critical as ensuring blood type compatibility. Priming the tubing and setting up the blood pump (Option B) and monitoring vital signs every 15 minutes (Option C) are essential steps in the transfusion process, but the primary concern should be preventing transfusion reactions by verifying blood type compatibility.

5. A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing?

• A. Assault
• B. Battery
• C. False imprisonment
• D. Invasion of privacy

Correct answer: A

Rationale: The correct answer is A: Assault. Assault involves making threats or using actions that cause the client to fear harm. In this scenario, the AP's threat to use diapers next time the urinal is used improperly constitutes as assault. Choice B, Battery, involves intentional harmful or offensive touching without consent, which is not evident in the scenario. Choice C, False imprisonment, refers to restraining or restricting a client's freedom of movement, which is not occurring in this situation. Choice D, Invasion of privacy, involves violating a client's right to privacy, which is also not applicable here.

Similar Questions