Nursing Elites

1. A nurse is planning to administer diltiazem via IV bolus to a client who has atrial fibrillation. Which of the following findings is a contraindication to the administration of diltiazem?

• A. Hypotension
• B. Tachycardia
• C. Decreased level of consciousness
• D. History of diuretic use

Correct answer: A

Rationale: The correct answer is A: Hypotension. Diltiazem, a calcium channel blocker, can cause hypotension. Administering diltiazem to a client with hypotension can further lower their blood pressure, leading to adverse effects like dizziness and syncope. Tachycardia (Choice B) is actually a common indication for diltiazem use, as it helps slow down the heart rate in conditions like atrial fibrillation. Decreased level of consciousness (Choice C) may require evaluation but is not a direct contraindication to diltiazem administration. History of diuretic use (Choice D) is not a contraindication to diltiazem, as the two medications can often be safely used together.

2. A client with diabetes is receiving education on foot care. Which of the following should be included in the teaching?

• A. Inspect feet daily for cuts and sores
• B. Soak feet in warm water daily
• C. Wear closed-toe shoes at all times
• D. Trim toenails straight across

Correct answer: A

Rationale: The correct answer is A: Inspect feet daily for cuts and sores. Clients with diabetes are at an increased risk of foot complications, so it is essential to check for any cuts, sores, or injuries daily to prevent infections and complications. Soaking feet in warm water daily (choice B) is not recommended as it can lead to skin breakdown. Wearing closed-toe shoes at all times (choice C) is not advisable as it can cause excessive pressure and friction. Trimming toenails straight across (choice D) is the correct method to prevent ingrown toenails, not trimming them in a rounded shape.

3. A nurse is preparing to administer a blood transfusion. Which of the following actions should the nurse take first?

• A. Obtain the client's consent
• B. Verify the blood type and crossmatch
• C. Take baseline vital signs
• D. Prime the IV with normal saline

Correct answer: B

Rationale: The correct first action the nurse should take when preparing to administer a blood transfusion is to verify the blood type and crossmatch. This step is crucial to ensure compatibility and prevent transfusion reactions. Obtaining the client's consent is important but should follow the verification process. Taking baseline vital signs is necessary before starting the transfusion, but confirming compatibility takes precedence. Priming the IV with normal saline is a step done before starting the transfusion, after ensuring blood compatibility.

4. A client receiving oxytocin IV for labor augmentation is experiencing contractions every 45 seconds. What action should the nurse take?

• A. Discontinue the oxytocin infusion
• B. Increase the oxytocin infusion
• C. Decrease the oxytocin infusion
• D. Maintain the oxytocin infusion

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to discontinue the oxytocin infusion. Contractions occurring every 45 seconds indicate uterine hyperstimulation, which can pose risks to both the client and the fetus. By stopping the oxytocin infusion, the nurse can help prevent further complications. Choices B, C, and D are incorrect because increasing, decreasing, or maintaining the oxytocin infusion can exacerbate the uterine hyperstimulation and increase the risks associated with it.

5. A client has been taking propranolol. Which of the following findings indicates a need to withhold the medication?

• A. Sodium 130 mEq/L
• B. Blood pressure 156/90 mm Hg
• C. Potassium 5.2 mEq/L
• D. Pulse 54/min

Correct answer: D

Rationale: A pulse of 54/min indicates bradycardia, which is a side effect of propranolol, a beta-blocker. The medication should be withheld if the client's pulse drops below 60/min. The other findings (sodium levels, blood pressure, and potassium levels) are not directly indicative of the need to withhold propranolol.

Similar Questions