Nursing Elites

1. The healthcare provider is monitoring a client following cardioversion. Which observation should be of the highest priority to the healthcare provider?

• A. Blood pressure
• B. Status of airway
• C. Oxygen flow rate
• D. Level of consciousness

Correct answer: B

Rationale: The status of the airway is the highest priority following cardioversion as it ensures proper oxygenation and helps prevent complications such as airway obstruction and respiratory distress. Maintaining a patent airway is crucial for the client's respiratory function and overall well-being immediately after cardioversion. Monitoring the airway ensures that the client can breathe effectively and minimizes the risk of hypoxia and other serious respiratory issues. While blood pressure, oxygen flow rate, and level of consciousness are also important parameters to monitor, they are secondary to ensuring a clear and patent airway for adequate oxygenation.

2. A healthcare professional is assessing a client who has been taking digoxin. Which of the following findings should the healthcare professional report to the provider?

• A. Weight gain
• B. Dry cough
• C. Hypokalemia
• D. Bradycardia

Correct answer: D

Rationale: The correct answer is D: Bradycardia. Bradycardia is a significant finding associated with digoxin toxicity. Digoxin, a medication commonly used to treat heart conditions, can lead to bradycardia as a sign of toxicity. Bradycardia requires immediate attention and reporting to the healthcare provider for further evaluation and management to prevent serious complications. Choices A, B, and C are incorrect because weight gain, dry cough, and hypokalemia are not specific signs of digoxin toxicity. While weight gain can be a side effect of digoxin, it is not a classic sign of toxicity. Dry cough is more commonly associated with medications like ACE inhibitors, and hypokalemia can be a complication of digoxin therapy but is not a direct sign of toxicity.

3. When educating a client with a new prescription for nitroglycerin, which of the following instructions should the nurse include?

• A. Store the medication in a cool, dark place.
• B. Take the medication before bedtime.
• C. Take the medication with food.
• D. Take the medication at the first sign of chest pain.

Correct answer: D

Rationale: The correct instruction for a client with a new prescription for nitroglycerin is to take the medication at the first sign of chest pain. Nitroglycerin is a vasodilator used to relieve chest pain associated with angina. Taking it at the onset of chest pain ensures prompt relief by dilating blood vessels and increasing blood flow to the heart muscle. Storing nitroglycerin in a cool, dark place helps maintain its potency, while taking it with food can alter its absorption. Timing the medication with bedtime is not necessary, but prompt administration at the first sign of chest pain is crucial for effective management of angina. Choices A, B, and C are incorrect because storing the medication in a cool, dark place, taking it before bedtime, and taking it with food are not essential instructions for nitroglycerin use. The priority is to administer it promptly when chest pain occurs to achieve optimal therapeutic effects.

4. The client will wear a Holter monitor for continuous cardiac monitoring over the next 24 hours. What action should the nurse take to assist the client?

• A. Shave the front of the client's chest
• B. Give the client a device holder to wear around the waist
• C. Teach the client to rest as much as possible during the next 24 hours
• D. Tell the client to cover the monitor in plastic wrap before taking a bath

Correct answer: B

Rationale: Providing the client with a device holder to wear around the waist allows them to comfortably carry the Holter monitor while engaging in normal activities throughout the 24-hour monitoring period. This approach supports the client's mobility and ensures the monitor is securely in place for accurate readings. Shaving the front of the client's chest is unnecessary and not a standard practice for Holter monitor placement. Instructing the client to rest as much as possible does not promote normal daily activities which are important for accurate monitoring. Covering the monitor in plastic wrap before bathing is not recommended as it may affect the functionality of the device.

5. The client with a history of heart failure is receiving digoxin (Lanoxin). Which electrolyte imbalance increases the risk of digoxin toxicity?

• A. Hypernatremia
• B. Hypercalcemia
• C. Hypokalemia
• D. Hypomagnesemia

Correct answer: C

Rationale: Hypokalemia increases the risk of digoxin toxicity as low potassium levels enhance the effects of digoxin on the heart, leading to toxicity and potential adverse effects. Hypernatremia (Choice A) is not directly associated with an increased risk of digoxin toxicity. Hypercalcemia (Choice B) does not increase the risk of digoxin toxicity. Hypomagnesemia (Choice D) can contribute to digoxin toxicity, but hypokalemia has a more significant impact on increasing the risk.

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