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. Which client statement from the assessment data is likely to explain their noncompliance with propranolol hydrochloride (Inderal)?

• A. I have problems with diarrhea.
• B. I have difficulty falling asleep.
• C. I have diminished sexual function.
• D. I often feel jittery.

Correct answer: C

Rationale: The correct answer is C. Propranolol hydrochloride (Inderal) is known to cause side effects such as diminished sexual function, which can lead to noncompliance with the medication due to its impact on quality of life. Choices A, B, and D are less likely to be associated with propranolol hydrochloride. While diarrhea, difficulty falling asleep, and feeling jittery are possible side effects of propranolol, they are not as commonly reported as diminished sexual function. Therefore, choice C is the most likely reason for the client's noncompliance.

3. Nurse talking with a client’s partner. She is having frustrations about managing responsibilities and care. What type of role performance stress is this?

• A. Role overload
• B. Role conflict
• C. Role ambiguity
• D. Role strain

Correct answer: A

Rationale: Role overload occurs when a person feels overwhelmed by the demands placed upon them.

4. The nurse is preparing to administer a medication through a nasogastric (NG) tube. Which action should the LPN/LVN take to ensure proper administration?

• A. Check the placement of the tube by auscultation.
• B. Flush the tube with 30 ml of water before and after medication administration.
• C. Administer the medication with food to prevent nausea.
• D. Dilute the medication with normal saline before administration.

Correct answer: B

Rationale: To ensure proper administration through a nasogastric tube, the LPN/LVN should flush the tube with 30 ml of water before and after medication administration. This action helps ensure the tube is patent, prevents clogging, and helps deliver the medication effectively. Checking the placement of the tube by auscultation (Choice A) is essential but does not directly relate to ensuring proper administration. Administering the medication with food (Choice C) may not always be appropriate for all medications and may not necessarily prevent nausea. Diluting the medication with normal saline (Choice D) is not a standard practice for all medications administered via an NG tube and may alter the medication's effectiveness.

5. The client is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which finding indicates that the bladder irrigation is effective?

• A. The client reports minimal pain and discomfort.
• B. The urine appears clear and free of clots.
• C. The client has no signs of infection.
• D. The client is able to void independently.

Correct answer: B

Rationale: The presence of clear urine free of clots is an indicator that the bladder irrigation is effective. This finding suggests that the irrigation is preventing clot formation and ensuring proper drainage, which is crucial after a TURP procedure. The client reporting minimal pain and discomfort (choice A) may be a positive sign but does not directly reflect the effectiveness of the bladder irrigation. The absence of infection signs (choice C) is important but not specific to evaluating the bladder irrigation. The client being able to void independently (choice D) is a good sign overall but does not specifically indicate the effectiveness of the bladder irrigation.

Similar Questions