Nursing Elites

1. Prior to giving digoxin, the PN assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this finding, what action should the PN take?

• A. Withhold the medication and notify the charge nurse
• B. Give the medication and document the heart rate
• C. Withhold the medication until the next scheduled dose
• D. Request the charge nurse to administer the medication

Correct answer: B

Rationale: A heart rate of 120 beats per minute is within the normal range for a 2-month-old infant. Therefore, it is safe to administer the digoxin and document the heart rate as part of routine care. Choice A is incorrect as withholding the medication is not necessary since the heart rate is normal. Choice C is incorrect as there is no need to delay the administration until the next scheduled dose when the heart rate is within the normal range. Choice D is incorrect as the primary nurse is not needed to administer the medication since the heart rate is normal and falls within the safe range for administration.

2. A client post-thoracotomy is complaining of severe pain with deep breathing and coughing. What should the nurse encourage the client to do to manage the pain and prevent respiratory complications?

• A. Hold a pillow against the chest while coughing (splinting).
• B. Take shallow breaths to avoid pain.
• C. Increase the dose of pain medication.
• D. Avoid deep breathing exercises.

Correct answer: A

Rationale: Splinting the chest with a pillow helps manage pain during deep breathing and coughing, which is essential to prevent respiratory complications such as atelectasis or pneumonia after thoracic surgery. Holding a pillow against the chest while coughing (splinting) supports the incision site and reduces the pain associated with deep breathing and coughing. Encouraging shallow breaths (Choice B) can lead to respiratory complications due to inadequate lung expansion. Increasing pain medication (Choice C) should be done based on healthcare provider orders and not solely for this situation. Avoiding deep breathing exercises (Choice D) can worsen respiratory function and increase the risk of complications.

3. Which type of isolation precaution is required for a patient with tuberculosis (TB)?

• A. Droplet precautions
• B. Contact precautions
• C. Airborne precautions
• D. Standard precautions

Correct answer: C

Rationale: The correct answer is C: Airborne precautions. Tuberculosis (TB) is transmitted via airborne particles, thus requiring airborne precautions to prevent the spread of infection. This includes using an N95 respirator to filter out small infectious particles. Droplet precautions (Choice A) are used for diseases that spread through large respiratory droplets. Contact precautions (Choice B) are for direct or indirect contact with the patient or their environment. Standard precautions (Choice D) are used for all patients to prevent the spread of infection through blood, bodily fluids, non-intact skin, and mucous membranes.

4. The PN is reviewing instructions for the use of pilocarpine eye drops with a client who has glaucoma. The client replies that the drops are used to anesthetize the eye if eye pain is experienced. What action should the PN implement?

• A. Document in the chart that the client understands the correct action and use of eye drops
• B. Reassure the client that the drops will not be needed often since eye pain in glaucoma is not common
• C. Reteach the client about the action of the eye drops to decrease pressure in the eyes
• D. Explain to the client that the eye drops do not anesthetize the eyes but reduce pressure

Correct answer: C

Rationale: Pilocarpine eye drops are used to reduce intraocular pressure in glaucoma, not to anesthetize the eye. The PN should reteach the client about the purpose of the medication to ensure proper use and understanding, which is crucial for effective treatment. Choice A is incorrect because just documenting understanding without addressing the client's misconception is not enough. Choice B is incorrect as it provides incorrect information about the purpose of the eye drops and may lead to further misunderstanding. Choice D is incorrect as it provides inaccurate information stating that the drops provide pain relief, which is not their primary purpose.

5. What is the primary function of hemoglobin in red blood cells?

• A. To transport oxygen from the lungs to body tissues
• B. To protect the body from infections
• C. To help in blood clotting
• D. To regulate body temperature

Correct answer: A

Rationale: The primary function of hemoglobin in red blood cells is to transport oxygen from the lungs to body tissues and return carbon dioxide from the tissues to the lungs. Hemoglobin binds to oxygen in the lungs and releases it in the body's tissues. Choice B is incorrect because hemoglobin is not involved in protecting the body from infections. Choice C is incorrect because blood clotting is mainly facilitated by platelets and clotting factors, not hemoglobin. Choice D is incorrect because the regulation of body temperature is mainly controlled by processes like sweating and shivering, not by hemoglobin.

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