Nursing Elites

1. A client with heart failure is prescribed digoxin and reports nausea. What is the nurse's first action?

• A. Administer an anti-nausea medication as prescribed.
• B. Assess the client's digoxin level immediately.
• C. Assess the client’s apical pulse and hold the next dose if it's below 60 bpm.
• D. Instruct the client to reduce their fluid intake.

Correct answer: B

Rationale: When a client on digoxin reports nausea, it can be a sign of digoxin toxicity. The priority action for the nurse is to assess the client's digoxin level immediately. This assessment will help determine if the nausea is related to digoxin toxicity, requiring a dosage adjustment. Administering an anti-nausea medication (Choice A) does not address the underlying issue of potential digoxin toxicity. Assessing the client's apical pulse (Choice C) is important in general digoxin monitoring but not the first action when nausea is reported. Instructing the client to reduce fluid intake (Choice D) is not the initial response to nausea in a client taking digoxin.

2. While assessing a client who is admitted with heart failure and pulmonary edema, the nurse identifies dependent peripheral edema, an irregular heart rate, and a persistent cough that produces pink blood-tinged sputum. After initiating continuous telemetry and positioning the client, which intervention should the nurse implement?

• A. Administer prescribed diuretics
• B. Prepare for intubation
• C. Notify the healthcare provider immediately
• D. Obtain sputum sample

Correct answer: D

Rationale: The client's cough producing pink, frothy sputum is indicative of pulmonary edema, which needs immediate treatment. Obtaining a sputum sample helps identify any infection that may be contributing to the pulmonary issues. Administering diuretics is essential in managing pulmonary edema but obtaining a sputum sample should take priority. Intubation may be necessary in severe cases but is not the initial intervention. Notifying the healthcare provider is important, but immediate action to diagnose and treat the condition is crucial.

3. A client with a prescription for DNR begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement?

• A. Inform the healthcare provider
• B. Determine the client's need for pain medication
• C. Begin comfort measures
• D. Ensure all life-saving equipment is removed

Correct answer: B

Rationale: The correct priority action for the nurse to implement in this scenario is to determine the client's need for pain medication. Ensuring that the client is comfortable and free from pain is crucial in end-of-life care, especially for a client with a Do Not Resuscitate (DNR) order. This action prioritizes the client's comfort and dignity in their final moments. While informing the healthcare provider and beginning comfort measures are important aspects of care, pain management takes precedence as the immediate priority. Removing life-saving equipment is not appropriate at this stage as it goes against the client's wishes stated in the DNR order.

4. The nurse is providing care for a client with schizophrenia who receives haloperidol decanoate 75 mg IM every 4 weeks. The client begins developing puckering and smacking of the lips and facial grimacing. Which intervention should the nurse implement?

• A. Discontinue the medication immediately
• B. Increase the dose of haloperidol
• C. Complete the abnormal involuntary movement scale (AIMS)
• D. Monitor the client for signs of agitation

Correct answer: C

Rationale: These symptoms are characteristic of tardive dyskinesia, a side effect of long-term antipsychotic use. The nurse should assess the severity of these movements using the AIMS scale and report to the healthcare provider for further management. Discontinuing the medication abruptly (Choice A) can lead to withdrawal symptoms and worsening of the condition. Increasing the dose of haloperidol (Choice B) can exacerbate the symptoms of tardive dyskinesia. Monitoring for signs of agitation (Choice D) is important but does not address the specific side effect described.

5. A client with chronic obstructive pulmonary disease (COPD) is prescribed home oxygen therapy. What teaching should the nurse provide?

• A. Ensure that the client uses oxygen continuously at night.
• B. Instruct the client to avoid smoking and exposure to smoke.
• C. Teach the client how to clean and replace the oxygen tubing.
• D. Instruct the client to increase their fluid intake.

Correct answer: C

Rationale: The correct teaching for a client with COPD prescribed home oxygen therapy is to educate them on how to clean and replace the oxygen tubing. This is crucial to prevent infections and ensure the effectiveness of the oxygen delivery system. Option A is not necessary as oxygen therapy is usually prescribed as needed, not continuously at night. While smoking cessation and avoiding smoke exposure are important in COPD management, it is not directly related to home oxygen therapy. Increasing fluid intake is beneficial for some conditions but is not specifically related to home oxygen therapy for COPD.

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