Nursing Elites

1. A client with heart failure is receiving digoxin. Which finding should indicate to the nurse that the client is experiencing digoxin toxicity?

• A. Constipation
• B. Blurred vision
• C. Bradycardia
• D. Dry cough

Correct answer: C

Rationale: Bradycardia is a hallmark sign of digoxin toxicity. Digoxin, a medication used to treat heart conditions, can lead to toxicity manifesting as bradycardia. Bradycardia occurs due to the drug's effect on slowing down the heart rate excessively. Constipation (Choice A) is not typically associated with digoxin toxicity. Blurred vision (Choice B) is more commonly linked to visual disturbances caused by digoxin, but it is not a defining sign of toxicity. Dry cough (Choice D) is not a recognized symptom of digoxin toxicity. It is crucial for the nurse to recognize the early signs of digoxin toxicity to prevent serious complications and provide appropriate interventions promptly.

2. A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following statements should the nurse include?

• A. Avoid using a soft toothbrush.
• B. Report any signs of bleeding.
• C. Increase your intake of leafy green vegetables.
• D. Take the medication with food.

Correct answer: B

Rationale: The correct answer is B: 'Report any signs of bleeding.' When a patient is prescribed warfarin, it is essential to monitor for signs of bleeding as warfarin is an anticoagulant that increases the risk of bleeding. Choices A, C, and D are incorrect. Avoid using a soft toothbrush is not directly related to warfarin therapy, increasing the intake of leafy green vegetables can interfere with warfarin's effectiveness due to its vitamin K content, and taking warfarin with food is unnecessary as it can be taken with or without food.

3. A client with a history of hypertension is being discharged on a low-sodium diet. Which statement by the client indicates a need for further teaching?

• A. I will use fresh herbs and spices instead of salt.
• B. I will avoid canned soups and processed foods.
• C. I can eat as much bacon and sausage as I want because they taste good.
• D. I will read food labels to check for sodium content.

Correct answer: C

Rationale: Choice C is the correct answer because bacon and sausage are high in sodium, which contradicts the low-sodium diet requirement. Consuming them freely would contribute to increased sodium intake, which is not suitable for managing hypertension. Choices A, B, and D demonstrate appropriate understanding and actions for a low-sodium diet, such as using alternatives to salt, avoiding processed foods, and checking food labels for sodium content.

4. When preparing to administer medication to a client, what action should the nurse take first?

• A. Verify the client's identity.
• B. Check the medication expiration date.
• C. Review the client's medical history.
• D. Obtain the client's vital signs.

Correct answer: A

Rationale: Verifying the client's identity is the initial and most critical step in medication administration. It is crucial to confirm that the right medication is being given to the correct patient. Checking the client's identity helps prevent medication errors and ensures patient safety. Checking the medication expiration date (choice B) is important but should come after verifying the client's identity. Reviewing the client's medical history (choice C) is valuable but not the first step in medication administration. Obtaining the client's vital signs (choice D) is essential in some situations but is usually not the first action needed before administering medication.

5. The LPN/LVN is assisting in the care of a client with a diagnosis of heart failure who is receiving digoxin (Lanoxin). Which laboratory result should the nurse monitor closely?

• A. Serum sodium
• B. Serum potassium
• C. Serum calcium
• D. Serum glucose

Correct answer: B

Rationale: The correct answer is serum potassium. Monitoring serum potassium levels is crucial when a client is receiving digoxin (Lanoxin) because low potassium levels can increase the risk of digoxin toxicity. Digoxin and low potassium levels can lead to serious cardiac complications, such as arrhythmias. Therefore, close monitoring of serum potassium is essential to prevent adverse effects and ensure the safe administration of digoxin in clients with heart failure. Serum sodium, serum calcium, and serum glucose levels are also important laboratory values to monitor in clients with heart failure, but they are not directly associated with the risk of digoxin toxicity. Monitoring these values helps in assessing overall health status, fluid balance, and metabolic functions in the client.

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