Nursing Elites

1. A nurse is reviewing a client's medication regimen. Which of the following medications places the client at increased risk for digoxin toxicity?

• A. Calcium channel blockers
• B. Potassium-sparing diuretics
• C. Beta blockers
• D. Loop diuretics

Correct answer: D

Rationale: The correct answer is D, Loop diuretics. Loop diuretics can lead to hypokalemia, which increases the risk for digoxin toxicity. Loop diuretics cause potassium loss, and hypokalemia can potentiate the toxic effects of digoxin. Choices A, B, and C are incorrect because calcium channel blockers, potassium-sparing diuretics, and beta blockers do not directly increase the risk of digoxin toxicity.

2. A nurse is caring for a client prescribed enoxaparin for deep vein thrombosis prophylaxis. Which of the following client assessments requires immediate intervention?

• A. Platelet count of 95,000/mm³
• B. Blood pressure of 145/90 mmHg
• C. Heart rate of 95 beats per minute
• D. Pain at the injection site

Correct answer: A

Rationale: A platelet count of 95,000/mm³ requires immediate intervention as it is low and increases the risk of bleeding, which is a potential complication of enoxaparin therapy. Low platelet counts can predispose the patient to hemorrhage, and administering anticoagulants like enoxaparin in such cases can further increase the bleeding risk. Monitoring platelet counts is crucial during anticoagulant therapy to prevent serious bleeding complications. The other options do not pose immediate risks related to enoxaparin therapy. A slightly elevated blood pressure, a heart rate of 95 beats per minute, and pain at the injection site are common findings that may not warrant immediate intervention in this context.

3. A client is prescribed digoxin 0.125 mg daily for heart failure. Which of the following client reports should concern the nurse as a sign of digoxin toxicity?

• A. Increased appetite
• B. Visual disturbances
• C. Weight gain
• D. Constipation

Correct answer: B

Rationale: Visual disturbances such as blurred vision or seeing halos around lights are common signs of digoxin toxicity. Increased appetite, weight gain, and constipation are not typically associated with digoxin toxicity. Weight gain could be a sign of worsening heart failure rather than digoxin toxicity. Increased appetite and constipation are not specific signs of digoxin toxicity and are less likely to be related.

4. A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL. How many mL should the nurse administer per dose?

• A. 0.2 mL
• B. 0.4 mL
• C. 0.6 mL
• D. 0.8 mL

Correct answer: A

Rationale: The nurse should administer 0.2 mL of morphine sulfate. To calculate this, divide the desired dose (2 mg) by the concentration of the available solution (10 mg/mL). 2 mg / 10 mg/mL = 0.2 mL. Therefore, the nurse should administer 0.2 mL of morphine sulfate. Choices B, C, and D are incorrect as they do not reflect the accurate calculation based on the provided concentration and desired dose.

5. A nurse is caring for a client prescribed clopidogrel. Which of the following client histories is a contraindication to the administration of this medication?

• A. Recent surgery
• B. Peptic ulcer disease
• C. Bleeding disorder
• D. Uncontrolled hypertension

Correct answer: D

Rationale: The correct answer is D: Uncontrolled hypertension. Clopidogrel should not be administered to clients with uncontrolled hypertension due to the increased risk of bleeding. Recent surgery, peptic ulcer disease, and bleeding disorders are not absolute contraindications for clopidogrel administration.

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