Nursing Elites

1. The client is on digoxin and has severe digoxin toxicity. What is the nursing priority action?

• A. Check the potassium level.
• B. Give Digibind as an antidote.
• C. Change the dosing of digoxin to every other day.
• D. Administer a potassium supplement to decrease digoxin toxicity.

Correct answer: B

Rationale: The correct answer is to give Digibind as an antidote in cases of severe digoxin toxicity. Digibind works by binding to digoxin and preventing it from causing further harm. Checking the potassium level (choice A) is important but not the priority when the client has severe toxicity. Changing the dosing to every other day (choice C) is not appropriate in the setting of severe toxicity where immediate action is required. Giving a potassium supplement (choice D) may be needed eventually, but the priority is to administer Digibind to counteract the toxic effects of digoxin.

2. The client on digoxin has a potassium level of 2.7 mEq/L. What is the nurse’s priority action?

• A. Hold the digoxin and notify the healthcare provider.
• B. Administer the digoxin as ordered.
• C. Increase the dose of digoxin.
• D. Administer potassium supplements.

Correct answer: A

Rationale: The correct answer is to hold the digoxin and notify the healthcare provider. A potassium level of 2.7 mEq/L is considered low and can increase the risk of digoxin toxicity. Holding the medication and informing the healthcare provider is crucial to prevent adverse effects. Administering the digoxin as ordered (Choice B) would put the client at a higher risk for toxicity. Increasing the dose of digoxin (Choice C) is not appropriate when the client's potassium level is low. Administering potassium supplements (Choice D) may be necessary but is not the priority action in this situation.

3. What is the condition where the body's immune system attacks its tissues, causing inflammation and damage?

• A. Autoimmune disease
• B. Infectious disease
• C. Allergic reaction
• D. Degenerative disease

Correct answer: A

Rationale: The correct answer is A: Autoimmune disease. Autoimmune diseases occur when the body's immune system mistakenly attacks its own tissues, leading to inflammation and damage. This is different from infectious diseases (choice B), which are caused by pathogenic microorganisms, allergic reactions (choice C), which involve an exaggerated response of the immune system to harmless substances, and degenerative diseases (choice D), which are characterized by progressive deterioration of tissue or organs due to various factors.

4. The client is on warfarin and has an INR of 1.5. What is the nurse’s priority action?

• A. Increase the dose of warfarin.
• B. Hold the next dose of warfarin.
• C. Continue the current dose of warfarin.
• D. Monitor the client’s INR closely.

Correct answer: B

Rationale: An INR of 1.5 is below the therapeutic range for a client on warfarin, indicating that the client may be at risk of clot formation. The nurse's priority action should be to hold the next dose of warfarin to prevent further reduction of the INR. Increasing the dose could potentially lead to an increased risk of bleeding, and continuing the current dose may not be sufficient to bring the INR within the therapeutic range. Monitoring the client's INR closely is important but not the priority action in this scenario.

5. Which heart chamber receives venous blood returning to the heart via the superior and inferior vena cava?

• A. Right atrium
• B. Left atrium
• C. Right ventricle
• D. Left ventricle

Correct answer: A

Rationale: The correct answer is A: Right atrium. The right atrium is the heart chamber that receives deoxygenated blood returning from the body via the superior and inferior vena cava. The blood enters the right atrium from the vena cava and then passes through the tricuspid valve into the right ventricle. Choices B, C, and D are incorrect because the left atrium receives oxygenated blood from the lungs, the right ventricle pumps blood to the lungs for oxygenation, and the left ventricle pumps oxygenated blood to the body.

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