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. The nurse is discharging an adult woman who was hospitalized for 6 days for treatment of pneumonia. While the nurse is reviewing the prescribed medications, the client appears anxious. What action is most important for the nurse to implement?

• A. Instruct the client to repeat the medication plan
• B. Encourage the client to take a PRN antianxiety drug
• C. Provide written instructions that are easy to follow
• D. Include a family member in the teaching session

Correct answer: D

Rationale: Including a family member in the teaching session is the most important action for the nurse to implement in this scenario. By involving a family member, the nurse can ensure that there is additional support and reinforcement of the medication plan. This can help the client and family better understand and adhere to the prescribed medications, reducing the client's anxiety. Instructing the client to repeat the medication plan (Choice A) may not address the client's anxiety effectively. Encouraging the client to take a PRN antianxiety drug (Choice B) should not be the first intervention without exploring other supportive measures. Providing written instructions (Choice C) alone may not offer the immediate support and reassurance needed for the anxious client.

3. A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge?

• A. Asks relevant questions regarding the dressing change.
• B. States he will be able to complete the wound care regimen.
• C. Demonstrates the wound care procedure correctly.
• D. Has all the necessary supplies for wound care.

Correct answer: C

Rationale: The correct answer is C. Demonstrating the wound care procedure correctly indicates the client's readiness to independently manage wound care. This action shows practical understanding and application of the necessary skills. Choice A, asking relevant questions, is important but does not directly demonstrate the ability to perform the procedure. Choice B, stating the ability to complete the regimen, is a good intention but does not confirm practical competence. Choice D, having necessary supplies, is essential but does not ensure the client's ability to execute proper wound care.

4. The nurse assesses a client who has a nasal cannula delivering oxygen at 2 L/min. To assess for skin damage related to the cannula, which areas should the nurse observe?

• A. Tops of the ears
• B. Bridge of the nose
• C. Around the nostrils
• D. Over the cheeks

Correct answer: A

Rationale: When a client is using a nasal cannula for oxygen therapy, the areas prone to skin damage are the tops of the ears and around the nostrils. The pressure exerted by the cannula on these areas can lead to skin breakdown, so it is important for the nurse to observe these sites for any signs of damage. The correct answer is 'Tops of the ears.' Choices 'Bridge of the nose' and 'Over the cheeks' are not typically areas where skin damage related to the cannula would occur, making them incorrect choices.

5. When caring for an older adult client who becomes agitated when asked to remove dentures before surgery, which of the following responses should the nurse make?

• A. "What worries you about being without your teeth?"
• B. "You need to follow the preoperative instructions and remove your dentures."
• C. "It's important to remove dentures to ensure proper fitting of the mask during anesthesia."
• D. "I will explain why dentures need to be removed before surgery."

Correct answer: A

Rationale: The correct response is to ask the client about their concerns regarding being without their teeth. This approach helps address the client's anxiety and provides insight into the reason for their agitation. Choice B is authoritarian and does not address the client's emotional needs. Choice C focuses on the technical aspect of surgery and does not address the client's emotional state. Choice D implies a one-way communication without addressing the client's feelings or concerns.

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