Nursing Elites

1. A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following findings should the nurse identify as a manifestation of digoxin toxicity?

• A. Constipation.
• B. Tachycardia.
• C. Visual disturbances.
• D. Hypertension.

Correct answer: C

Rationale: Visual disturbances, such as blurred or yellow vision, are common signs of digoxin toxicity. While constipation (Choice A) is not typically associated with digoxin toxicity, tachycardia (Choice B) and hypertension (Choice D) are not characteristic manifestations of digoxin toxicity. Therefore, the correct answer is visual disturbances (Choice C).

2. A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 60/min
• B. Respiratory rate of 16/min
• C. Sodium level of 138 mEq/L
• D. Weight gain of 1.5 kg (3.3 lb) in 24 hours

Correct answer: D

Rationale: The correct answer is D. A weight gain of 1.5 kg (3.3 lb) in 24 hours can indicate fluid retention and worsening heart failure in clients taking digoxin. This rapid weight gain could be due to fluid accumulation, a common sign of heart failure exacerbation. Reporting this finding to the provider is crucial for prompt intervention. Choices A, B, and C are within normal ranges and not directly indicative of worsening heart failure in this context, making them less urgent to report compared to the significant weight gain.

3. A nurse is planning care for a client who has pneumonia. Which of the following actions should the nurse take to promote airway clearance?

• A. Perform chest physiotherapy every 4 hours.
• B. Suction the client every 2 hours.
• C. Encourage the client to increase fluid intake.
• D. Administer oxygen via nasal cannula.

Correct answer: C

Rationale: Encouraging the client to increase fluid intake is essential in promoting airway clearance for a client with pneumonia. Increased fluid intake helps thin secretions, making it easier for the client to clear their airways. Chest physiotherapy (Choice A) is more focused on mobilizing secretions and may not be suitable for all clients with pneumonia. Suctioning (Choice B) is indicated for clients who have excessive secretions that they cannot manage effectively themselves. Administering oxygen via nasal cannula (Choice D) is important for clients with pneumonia to maintain adequate oxygenation, but it does not directly promote airway clearance.

4. Which medication is commonly prescribed for a patient with a history of heart failure?

• A. Furosemide
• B. Metoprolol
• C. Digoxin
• D. Aspirin

Correct answer: A

Rationale: Furosemide is the correct answer. It is a common diuretic used in patients with heart failure to reduce fluid overload. Metoprolol (Choice B) is a beta-blocker often prescribed to manage heart failure symptoms by improving heart function. Digoxin (Choice C) is used in heart failure patients to help the heart beat stronger and with a more regular rhythm. Aspirin (Choice D) is not typically prescribed for heart failure but may be used in patients with heart disease for its antiplatelet effects.

5. A nurse is developing a care plan for a client who is receiving nitroprusside for severe hypertension. Which action should the nurse include?

• A. Administer calcium gluconate at the bedside.
• B. Monitor blood pressure every 2 hours.
• C. Limit light exposure to the infusion.
• D. Keep the client on NPO status.

Correct answer: C

Rationale: The correct action the nurse should include in the care plan for a client receiving nitroprusside for severe hypertension is to limit light exposure to the infusion. Nitroprusside is light-sensitive, so it should be protected from light exposure to prevent degradation. Administering calcium gluconate at the bedside is not directly related to nitroprusside administration. Monitoring blood pressure every 2 hours is a good practice but is not specifically related to the administration of nitroprusside. Keeping the client on NPO status is not necessary solely based on receiving nitroprusside.

Similar Questions