Nursing Elites

1. A client has a new prescription for Digoxin. Which of the following findings should the nurse identify as a potential sign of Digoxin toxicity?

• A. Nausea
• B. Dry mouth
• C. Hypoglycemia
• D. Tinnitus

Correct answer: A

Rationale: Nausea is a potential sign of Digoxin toxicity. Other signs of Digoxin toxicity include vomiting, visual disturbances, and confusion. Nausea can be an early indicator of toxicity and should be closely monitored by the nurse. Dry mouth and hypoglycemia are not typically associated with Digoxin toxicity. Tinnitus is more commonly associated with medications like aspirin or loop diuretics, not Digoxin.

2. A healthcare professional is preparing to administer a transfusion of a unit of packed red blood cells (PRBCs) for a client who has severe anemia. Which of the following interventions will prevent an acute hemolytic reaction?

• A. Ensure that the client has a patent IV line before obtaining the blood product from the refrigerator.
• B. Obtain help from another healthcare professional to confirm the correct client and blood product.
• C. Take a complete set of vital signs before beginning the transfusion and periodically during the transfusion.
• D. Stay with the client for the first 15 to 30 minutes of the transfusion.

Correct answer: B

Rationale: Obtaining help from another healthcare professional to confirm the correct client and blood product is crucial in preventing an acute hemolytic reaction during a blood transfusion. This reaction occurs due to ABO or Rh incompatibility. Verifying the correct client and blood product reduces the risk of administering the wrong blood type, which could lead to a life-threatening reaction. Checking for patency of the IV line (Choice A) is important but does not directly prevent an acute hemolytic reaction. Monitoring vital signs (Choice C) is essential for detecting transfusion reactions but does not prevent them. Staying with the client (Choice D) is important for early recognition of adverse reactions but does not address the root cause of preventing an acute hemolytic reaction.

3. A client has a new prescription for Clonidine to assist with maintenance of abstinence from opioids. The nurse should instruct the client to monitor for which of the following adverse effects?

• A. Diarrhea
• B. Dry mouth
• C. Insomnia
• D. Hypertension

Correct answer: B

Rationale: Dry mouth is a common adverse effect associated with Clonidine use. Clonidine is known to cause a reduction in saliva production, leading to dry mouth. Monitoring for this adverse effect is essential to ensure client comfort and compliance with the medication. Diarrhea is not a common adverse effect of Clonidine. Insomnia is more commonly associated with opioid withdrawal rather than Clonidine use. While Clonidine is used to treat hypertension, it is not typically an adverse effect of the medication.

4. A client is prescribed Diltiazem. Which of the following findings should the nurse monitor?

• A. Tachycardia
• B. Bradycardia
• C. Hypertension
• D. Hyperkalemia

Correct answer: B

Rationale: Diltiazem is a calcium channel blocker that can cause bradycardia as an adverse effect due to its negative chronotropic properties, slowing down the heart rate. Therefore, the nurse should monitor the client for signs of bradycardia by regularly assessing the heart rate to prevent potential complications. Monitoring for tachycardia (choice A) is incorrect as diltiazem typically does not cause tachycardia. Hypertension (choice C) is not a typical finding to monitor for with diltiazem use. Hyperkalemia (choice D) is not directly associated with diltiazem administration.

5. A client requests information on the use of Feverfew. Which of the following responses should the nurse make?

• A. It is used to treat skin infections.
• B. It can decrease the frequency of migraine headaches.
• C. It can lessen nasal congestion in the common cold.
• D. It can relieve nausea of morning sickness during pregnancy.

Correct answer: B

Rationale: The correct response is B: Feverfew is commonly used to decrease the frequency of migraine headaches. However, it is important to note that it has not been proven to relieve an existing migraine headache. Choices A, C, and D are incorrect as Feverfew is not typically used for treating skin infections, lessening nasal congestion in the common cold, or relieving nausea of morning sickness during pregnancy.

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