Nursing Elites

1. A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug?

• A. diaphoresis with decreased urinary output
• B. increased heart rate with increased respirations
• C. improved respiratory status and increased urinary output
• D. decreased chest pain and decreased blood pressure

Correct answer: C

Rationale: When evaluating the therapeutic effectiveness of digoxin in a client with heart failure, the nurse should expect to find improved respiratory status and increased urinary output. Digoxin helps improve cardiac output and reduces fluid accumulation, leading to improved breathing and increased urinary output. Choices A, B, and D are incorrect because diaphoresis with decreased urinary output, increased heart rate with increased respirations, and decreased chest pain with decreased blood pressure are not indicative of the therapeutic effectiveness of digoxin in heart failure management.

2. A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea. Which of these actions should the nurse perform first?

• A. Administer oxygen therapy
• B. Encourage the client to perform deep breathing exercises
• C. Raise the head of the bed
• D. Check the client's oxygen saturation level

Correct answer: D

Rationale: The correct answer is to check the client's oxygen saturation level first. This action is crucial in assessing the severity of dyspnea and determining the necessity for oxygen therapy. Administering oxygen therapy without knowing the current oxygen saturation level can be inappropriate and potentially harmful. Encouraging deep breathing exercises and raising the head of the bed are important interventions, but assessing the oxygen saturation level takes precedence in managing dyspnea in a client with COPD.

3. An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next?

• A. Stay with the client and observe for airway obstruction
• B. Collect pillows and pad the side rails of the bed
• C. Place an oral airway in the mouth and suction
• D. Announce a cardiac arrest and assist with intubation

Correct answer: A

Rationale: The correct action for the nurse to take next is to stay with the client and observe for airway obstruction. This is crucial as it ensures immediate intervention if there is any airway compromise. Choice B is incorrect as padding the side rails of the bed is not the priority in this situation. Choice C is incorrect because inserting an oral airway and suctioning should only be done if there is evidence of airway obstruction, and it is not the initial step. Choice D is incorrect as announcing a cardiac arrest and assisting with intubation is not the immediate action needed when a client is seizing and losing consciousness.

4. Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls?

• A. Sensory perceptual alterations related to decreased vision
• B. Alteration in mobility related to fatigue
• C. Impaired gas exchange related to retained secretions
• D. Altered patterns of urinary elimination related to nocturia

Correct answer: D

Rationale: The correct answer is D: Altered patterns of urinary elimination related to nocturia. Nocturia increases the risk of falls in elderly clients due to frequent nighttime trips to the bathroom. Choice A is incorrect because while decreased vision can contribute to falls, nocturia poses a more direct risk. Choice B is incorrect as fatigue may affect mobility but is not as directly linked to falls as nocturia. Choice C is incorrect as impaired gas exchange is not typically associated with an increased risk of falls.

5. A nurse is reinforcing teaching with a client who has Crohn's disease about foods to include in her diet. Which of the following foods should the nurse include in the teaching?

• A. Vanilla milkshake
• B. Buttered popcorn
• C. Broccoli
• D. Grilled chicken breast

Correct answer: D

Rationale: Grilled chicken breast is a high-protein, low-fiber food that is well-tolerated by clients with Crohn's disease. Crohn's disease is an inflammatory bowel disease that often requires a low-fiber diet to reduce irritation to the digestive tract. Vanilla milkshake is high in dairy and sugar content, which may trigger symptoms in some individuals with Crohn's disease. Buttered popcorn and broccoli are high in fiber, which can be difficult for individuals with Crohn's disease to digest and may exacerbate symptoms.

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