Nursing Elites

1. A client has a new prescription for enoxaparin. Which of the following instructions should the nurse include?

• A. Massage the injection site after administering the medication.
• B. Pinch the skin while administering the injection.
• C. Administer the medication at bedtime.
• D. Aspirate before injecting the medication.

Correct answer: B

Rationale: When administering enoxaparin, it is important to pinch the skin to ensure proper subcutaneous injection. Massaging the injection site after administering the medication is not recommended. Administering the medication at bedtime is not a specific requirement for enoxaparin. Aspirating before injecting the medication is not necessary for subcutaneous injections like enoxaparin.

2. A healthcare provider is reviewing the laboratory report of a client with a prescription for digoxin. Which result requires withholding the medication?

• A. Digoxin 0.8 ng/mL
• B. Sodium 145 mEq/L
• C. BUN 20 mg/dL
• D. Potassium 3.1 mEq/L

Correct answer: D

Rationale: The correct answer is D. A low potassium level (3.1 mEq/L) can increase the risk of digoxin toxicity. Hypokalemia can potentiate the effects of digoxin on the heart, leading to serious dysrhythmias. Choices A, B, and C are within normal ranges and do not indicate a need to withhold digoxin.

3. A nurse is planning care for a client who has osteoarthritis. Which of the following interventions should the nurse include?

• A. Administer opioids routinely for chronic pain.
• B. Instruct the client to avoid weight-bearing exercises.
• C. Apply heat to affected joints to reduce stiffness.
• D. Avoid physical activity to prevent joint damage.

Correct answer: C

Rationale: The correct intervention for a client with osteoarthritis is to apply heat to affected joints to reduce stiffness. Heat application helps improve circulation, relax muscles, and reduce discomfort in joints affected by osteoarthritis. Administering opioids routinely (Choice A) is not the first-line treatment for osteoarthritis and carries risks of dependency and side effects. Instructing the client to avoid weight-bearing exercises (Choice B) may lead to muscle weakness and reduced joint flexibility. Avoiding physical activity altogether (Choice D) can lead to further joint stiffness and compromised overall health.

4. A nurse is assessing a client who has a deep vein thrombosis (DVT). Which of the following findings should the nurse report to the provider?

• A. Calf tenderness.
• B. Shortness of breath.
• C. Elevated blood pressure.
• D. Respiratory rate of 18/min.

Correct answer: B

Rationale: Shortness of breath is a critical finding that can indicate a pulmonary embolism, a severe complication of DVT. This symptom suggests a potential life-threatening situation and requires immediate intervention. Calf tenderness, while common in DVT, is not as urgent as shortness of breath. Elevated blood pressure and a respiratory rate of 18/min are important to assess but are not typically as indicative of a serious complication like a pulmonary embolism.

5. What is the priority nursing action for a patient with respiratory distress?

• A. Administer oxygen
• B. Reposition the patient
• C. Administer bronchodilators
• D. Provide chest physiotherapy

Correct answer: A

Rationale: The priority nursing action for a patient with respiratory distress is to administer oxygen. Oxygen therapy is crucial in improving oxygenation levels and relieving respiratory distress, making it the top priority intervention. Repositioning the patient, administering bronchodilators, or providing chest physiotherapy may be necessary interventions depending on the underlying cause, but ensuring adequate oxygen supply should take precedence in addressing respiratory distress.

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