Nursing Elites

1. The nurse is preparing to administer digoxin (Lanoxin) to a client with heart failure. Which assessment finding would prompt the nurse to withhold the medication and contact the healthcare provider?

• A. Heart rate of 55 beats per minute
• B. Blood pressure of 140/90 mmHg
• C. Respiratory rate of 20 breaths per minute
• D. Blood glucose level of 150 mg/dL

Correct answer: A

Rationale: A heart rate below 60 beats per minute is a contraindication for administering digoxin, as it can lead to bradycardia. Bradycardia is a common adverse effect associated with digoxin toxicity. Blood pressure of 140/90 mmHg, respiratory rate of 20 breaths per minute, and blood glucose level of 150 mg/dL are within normal limits and would not warrant withholding the medication or contacting the healthcare provider in this context. Therefore, a heart rate of 55 beats per minute would prompt the nurse to withhold digoxin and notify the healthcare provider.

2. A client has left lower atelectasis. In which of the following positions should the nurse place the client for postural drainage?

• A. Supine and low Fowler's position
• B. Right lateral in Trendelenburg position
• C. Side lying with the right side of the chest elevated
• D. Prone with pillows under the extremities

Correct answer: B

Rationale: Postural drainage is a technique used to help remove secretions from specific lung segments. For left lower atelectasis, placing the client in the right lateral Trendelenburg position is most effective. This position helps target the affected area, using gravity to assist in drainage. Placing the client in a supine or low Fowler's position (Choice A) may not effectively target the affected area. Side lying with the right side of the chest elevated (Choice C) would not utilize gravity for optimal drainage. Placing the client prone with pillows under the extremities (Choice D) is not ideal for postural drainage of the left lower lobe.

3. The healthcare professional is preparing to administer an intramuscular injection to an adult client. Which site is most appropriate for the LPN/LVN to use?

• A. Deltoid muscle
• B. Ventrogluteal site
• C. Dorsogluteal site
• D. Rectus femoris site

Correct answer: B

Rationale: The ventrogluteal site is the most appropriate and safest site for administering an intramuscular injection to an adult client. It is preferred due to its thick muscle mass and fewer major blood vessels and nerves in the area, reducing the risk of injury or complications. The deltoid muscle is commonly used for vaccines and small-volume injections but may not be suitable for larger volumes. The dorsogluteal site has fallen out of favor due to the risk of injury to the sciatic nerve and other underlying structures. The rectus femoris site is not typically used for intramuscular injections in adults.

4. A client who is postoperative is using an incentive spirometer. Into which of the following positions should the nurse place the client?

• A. Side-lying
• B. Supine
• C. Semi-Fowler’s
• D. Trendelenburg

Correct answer: C

Rationale: The correct position for a postoperative client using an incentive spirometer is the Semi-Fowler’s position. Placing the client in Semi-Fowler’s or high-Fowler’s position maximizes lung expansion and the effectiveness of the incentive spirometer. Side-lying may not provide optimal lung expansion. The supine position is not ideal for postoperative clients using incentive spirometers as it may limit lung expansion. The Trendelenburg position is not recommended due to potential complications postoperatively.

5. The healthcare professional is preparing to administer potassium chloride intravenously to a client with hypokalemia. Which action is most important?

• A. Monitor the client's respiratory rate
• B. Check the client's urine output
• C. Administer the potassium chloride as a rapid IV push
• D. Dilute the potassium chloride in an appropriate IV solution

Correct answer: D

Rationale: The correct answer is to dilute the potassium chloride in an appropriate IV solution. Potassium chloride should never be administered as a rapid IV push as it can lead to severe complications, including cardiac arrhythmias. Diluting the medication and administering it slowly helps reduce the risk of adverse effects. Monitoring the client's respiratory rate (Choice A) and checking urine output (Choice B) are important aspects of patient assessment but not the most crucial when administering potassium chloride. Administering potassium chloride as a rapid IV push (Choice C) is dangerous and can result in serious harm to the client.

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