Nursing Elites

1. A client is receiving digoxin therapy. Which of the following should the nurse monitor?

• A. Liver function
• B. Serum electrolytes
• C. Blood pressure
• D. All of the above

Correct answer: D

Rationale: When a client is receiving digoxin therapy, it is crucial for the nurse to monitor liver function, serum electrolytes (especially potassium levels), and blood pressure. Digoxin is known to affect the heart's electrical activity and can lead to toxic effects if not managed properly. Monitoring liver function helps to assess the drug's metabolism and excretion. Checking serum electrolytes, especially potassium, is essential because digoxin toxicity can be exacerbated by electrolyte imbalances, particularly hypokalemia. Monitoring blood pressure is necessary because digoxin can influence cardiac contractility and heart rate, potentially affecting blood pressure. Therefore, monitoring all these parameters is vital to ensure the client's safety and therapeutic effectiveness of digoxin. Choices A, B, and C are incorrect because monitoring only one or two of these parameters may not provide a comprehensive assessment of the client's response to digoxin therapy.

2. A client has been prescribed ferrous sulfate. Which instruction should the nurse provide to the client?

• A. Avoid strawberries, citrus fruits, and melon to improve absorption
• B. Take with fluids other than coffee or tea
• C. Take on a full stomach
• D. Double the dose if you miss a dose one day

Correct answer: B

Rationale: The correct instruction the nurse should provide to a client prescribed ferrous sulfate is to take it with fluids other than coffee or tea. Coffee and tea can inhibit iron absorption. Therefore, choices A, C, and D are incorrect. Avoiding strawberries, citrus fruits, and melon is not necessary for improving absorption of ferrous sulfate, taking it on a full stomach is not recommended, and doubling the dose if a dose is missed can lead to an overdose.

3. A nurse is assessing a client who has a blood glucose level of 250 mg/dL. Which of the following clinical manifestations is associated with this finding?

• A. Confusion
• B. Thirst
• C. Diaphoresis
• D. Shakiness

Correct answer: B

Rationale: Corrected Detailed Rationale: A blood glucose level of 250 mg/dL indicates hyperglycemia. Thirst (polydipsia) is a common clinical manifestation associated with hyperglycemia. The body tries to compensate for the high blood sugar by increasing fluid intake. Confusion (choice A) is more commonly associated with hypoglycemia, not hyperglycemia. Diaphoresis (choice C) and shakiness (choice D) are typical manifestations of hypoglycemia, not hyperglycemia. Therefore, the correct answer is increased thirst (polydipsia) in response to the elevated blood glucose level.

4. A nurse is assessing a client with suspected myocardial infarction. Which finding should the nurse report to the provider?

• A. Pain radiating to the left arm
• B. Pain relieved by rest
• C. Pain worsened with breathing
• D. Pain relieved by antacids

Correct answer: A

Rationale: The correct answer is A: Pain radiating to the left arm. This is a classic symptom of myocardial infarction and indicates possible heart involvement. Reporting this finding to the provider is crucial for prompt evaluation and intervention. Choices B, C, and D are incorrect. Pain relieved by rest, pain worsened with breathing, and pain relieved by antacids are not typical symptoms of myocardial infarction. These findings do not raise the same level of concern as pain radiating to the left arm and are less indicative of cardiac involvement.

5. A client newly diagnosed with asthma is receiving discharge instructions from a nurse. Which statement by the client indicates an understanding of the teaching?

• A. I will use my fluticasone inhaler to treat asthma attacks.
• B. I will use a peak flow meter once a week.
• C. I will keep a diary of when I use my albuterol inhaler.
• D. I will limit my fluid intake to prevent mucus production.

Correct answer: C

Rationale: The correct answer is C. Keeping a diary of albuterol use helps monitor the frequency and severity of asthma symptoms, which can guide the healthcare provider in adjusting treatment as needed. Option A is incorrect because fluticasone is a controller medication used for long-term management, not for treating acute asthma attacks. Option B is incorrect as using a peak flow meter once a week may not provide real-time information on asthma control. Option D is incorrect as limiting fluid intake does not directly prevent mucus production in asthma.

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