Nursing Elites

1. A client is receiving discharge teaching about a new prescription for digoxin (Lanoxin). Which statement by the client indicates a need for further teaching?

• A. I should avoid foods high in potassium while taking this medication.
• B. I will check my pulse before taking the medication.
• C. I should avoid taking antacids simultaneously with this medication.
• D. I will take the medication at the same time every day.

Correct answer: A

Rationale: The correct answer is A because clients taking digoxin should avoid foods high in potassium. High potassium levels can potentiate the effects of digoxin, leading to toxicity. Choices B, C, and D are correct statements regarding digoxin administration. Checking the pulse before taking the medication helps monitor for signs of digoxin toxicity. Avoiding taking antacids simultaneously prevents interactions that may reduce digoxin absorption. Taking the medication at the same time every day helps maintain a consistent blood level, ensuring optimal therapeutic effects.

2. Before donning gloves to perform a procedure, proper hand hygiene is essential. The healthcare professional understands that the most important aspect of hand hygiene is the amount of:

• A. Temperature
• B. Time
• C. Friction
• D. Soap

Correct answer: C

Rationale: The correct answer is C: Friction. The amount of friction is crucial in effective hand hygiene to remove microorganisms. Rubbing hands together with friction helps to dislodge and remove dirt, oils, and microorganisms. While temperature and soap are important factors in hand hygiene, the mechanical action of friction plays a more significant role in physically removing contaminants. Time is also important in hand hygiene practice, but without adequate friction, the effectiveness of the process is compromised.

3. A healthcare provider is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the healthcare provider take?

• A. Insert the IV catheter without using a tourniquet.
• B. Use the tourniquet minimally or not at all to avoid injury to fragile skin or veins.
• C. Insert the IV catheter at a 45-degree angle.
• D. Use a smaller gauge catheter to reduce vein trauma.

Correct answer: B

Rationale: When initiating IV therapy in older adults, it is essential to use the tourniquet minimally or not at all to prevent potential injury to fragile skin or veins. The use of a tourniquet can lead to increased venous pressure and potentially cause vein damage in older adult clients. Choice A is incorrect because inserting the IV catheter without a tourniquet can make locating veins more challenging. Choice C is incorrect as inserting the IV catheter at a 45-degree angle is not a recommended practice and can increase the risk of complications. Choice D is incorrect because using a smaller gauge catheter may not be appropriate for older adults who may require a larger gauge catheter for adequate fluid administration.

4. The nurse is caring for a client with diabetes insipidus. Which finding should the LPN/LVN report to the healthcare provider?

• A. Weight gain
• B. Increased urine output
• C. Low blood pressure
• D. Thirst

Correct answer: B

Rationale: The correct answer is B: Increased urine output. In diabetes insipidus, there is a deficiency of antidiuretic hormone (ADH), leading to the excretion of large amounts of dilute urine. Reporting increased urine output is crucial as it is a hallmark sign of diabetes insipidus. Weight gain (choice A) is not typically associated with diabetes insipidus; instead, clients may experience weight loss due to fluid loss. Low blood pressure (choice C) can be a complication of diabetes insipidus due to dehydration from excessive urination, but the priority finding to report is the increased urine output. Thirst (choice D) is a common symptom of diabetes insipidus due to the body's attempt to compensate for fluid loss, but it is not the most critical finding to report.

5. Which statement made by a client indicates to the nurse that they may have a thought disorder?

• A. 'I'm so angry about this. Wait until my partner hears about this.'
• B. 'I'm a little confused. What time is it?'
• C. 'I can't find my missing shoes. Have you seen them?'
• D. 'I'm fine. It's my daughter who has the problem.'

Correct answer: C

Rationale: The statement 'I can't find my missing shoes. Have you seen them?' displays disorganized thinking or speech, which is characteristic of a thought disorder. The mention of 'missing shoes' in a context that does not make logical sense suggests a disturbance in thought processes. Choices A, B, and D do not demonstrate disorganized thinking typical of thought disorders. Option A reflects emotional expression, option B indicates mild confusion, and option D shows a redirection of focus to someone else's problem.

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