Nursing Elites

1. A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication:

• A. Can predispose to dysrhythmias
• B. May lead to oliguria
• C. May cause irritability and anxiety
• D. Sometimes alters consciousness

Correct answer: A

Rationale: The correct answer is A: Hypokalemia increases the risk of dysrhythmias when taking digoxin, making potassium intake crucial. Digoxin toxicity is more likely in patients with low potassium levels, leading to an increased risk of dysrhythmias. Choices B, C, and D are incorrect because hypokalemia in combination with digoxin is primarily associated with dysrhythmias rather than oliguria, irritability, anxiety, or alteration of consciousness.

2. A nurse is reinforcing teaching to transition from breastfeeding to whole milk with the parents of an infant. Which of the following months of age should the nurse recommend for transitioning the infant to whole milk?

• A. 6 months
• B. 8 months
• C. 10 months
• D. 12 months

Correct answer: D

Rationale: The correct answer is D: 12 months. Whole milk should be introduced at 12 months to ensure the infant's digestive system can handle the increased fat content. Introducing whole milk before 12 months can lead to digestive issues and potential allergies. Choices A, B, and C are incorrect because transitioning to whole milk before 12 months is not recommended for infants due to their digestive system still developing and not being able to handle the higher fat content of whole milk.

3. The client is preparing for a myelogram. Which of the following statements by the client indicates a contraindication for this test?

• A. I can't lie in one position for more than thirty minutes.
• B. I am allergic to shrimp.
• C. I suffer from claustrophobia.
• D. I developed a severe headache after a spinal tap.

Correct answer: B

Rationale: An allergy to shrimp is a contraindication for a myelogram because the contrast dye used in the procedure contains iodine, which can trigger allergic reactions in individuals allergic to shellfish. Choices A, C, and D are not contraindications for a myelogram. Inability to lie still for an extended period, claustrophobia, or a previous headache after a spinal tap are concerns that can be managed during the procedure but do not necessarily prevent the test from being performed.

4. The parents of a child on phenytoin (Dilantin) have received discharge instructions from the nurse. Which of the following statements suggests that the teaching was effective?

• A. We will call the healthcare provider if the child develops acne.
• B. Our child should brush and floss carefully after every meal.
• C. We will skip the next dose if vomiting or fever occurs.
• D. When our child is seizure-free for 6 months, we can stop the medication.

Correct answer: B

Rationale: The correct answer is B. Proper oral hygiene, including brushing and flossing carefully after every meal, is essential for children on phenytoin to prevent gingival hyperplasia, a common side effect. Choice A is incorrect because acne is not a common side effect of phenytoin and does not require immediate healthcare provider notification. Choice C is incorrect because vomiting or fever should not prompt skipping a dose without consulting the healthcare provider first. Choice D is incorrect because discontinuing phenytoin should never be done abruptly or without healthcare provider guidance, even if the child is seizure-free for 6 months.

5. A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to

• A. have the client identify coping methods
• B. get the description of the location and intensity of the pain
• C. accept the client's report of pain
• D. determine the client's status of pain

Correct answer: B

Rationale: The correct answer is B: 'get the description of the location and intensity of the pain.' When a client complains of pain, the initial step in pain assessment is to gather information about the location and intensity of the pain. This helps the nurse understand the nature of the pain and lays the groundwork for further assessment and management. Choice A is incorrect because identifying coping methods comes later in the assessment process. Choice C is incorrect as accepting the client's report of pain is important, but not the first step. Choice D is incorrect as determining the client's pain status also comes after gathering information about the pain.

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