Nursing Elites

1. The nurse is providing discharge teaching to a client who has a new prescription for digoxin (Lanoxin). Which statement by the client indicates a need for further teaching?

• A. I will take my pulse before taking the medication.
• B. I will take the medication at the same time every day.
• C. I should avoid taking antacids at the same time as this medication.
• D. I should eat foods high in potassium while taking this medication.

Correct answer: D

Rationale: The correct answer is D. Clients taking digoxin should avoid eating foods high in potassium, as this can affect the medication's efficacy. Choices A, B, and C are correct statements regarding digoxin administration and precautions, indicating the client's understanding of the medication and its management.

2. A caregiver is talking with the caregivers of a 10-year-old child who is concerned that their child is becoming secretive, including closing the door when showering and dressing. Which of the following responses should the caregiver make?

• A. “Perhaps you should try to find out what is happening behind those closed doors.”
• B. “Suggest that the door be left ajar for safety reasons.”
• C. “At this age, children tend to become modest and value their privacy.”
• D. “You should establish a disciplinary plan to stop this behavior.”

Correct answer: C

Rationale: The correct response is C: “At this age, children tend to become modest and value their privacy.” During the developmental stage around 10 years old, children often start to value their privacy more and exhibit behaviors like closing doors when showering or dressing. It is a normal part of growing up and developing a sense of modesty. Choice A is incorrect as it suggests prying into the child's privacy, which may be counterproductive and invasive. Choice B is not the best response as it focuses on safety but fails to address the child's developmental stage and need for privacy. Choice D is also incorrect as it advocates for discipline without recognizing the normal developmental behavior of children at this age.

3. A client on a telemetry unit is being cared for by a nurse after a myocardial infarction. The client expresses, 'All this equipment is making me nervous.' Which of the following responses should the nurse make?

• A. 'All of this equipment can be frightening.'
• B. 'The equipment is necessary to monitor your condition.'
• C. 'You should try to ignore the equipment.'
• D. 'Try to relax; the equipment is not harmful.'

Correct answer: A

Rationale: Choice A is the most appropriate response as it acknowledges the client's feelings, showing empathy and understanding. It validates the client's experience, which can help reduce anxiety and build rapport. Choice B provides information but may not address the client's emotional needs. Choice C dismisses the client's concerns and does not offer support. Choice D minimizes the client's feelings and may not effectively address their anxiety.

4. While observing a student nurse administering a narcotic analgesic IM injection without aspirating, what should the nurse do?

• A. Ask the student, 'What did you forget to do?'
• B. Stop and explain why aspiration is needed.
• C. Quietly state, 'You forgot to aspirate.'
• D. Walk up and whisper in the student's ear, 'Stop. Aspirate. Then inject.'

Correct answer: D

Rationale: When the nurse observes a student nurse making a mistake during a procedure, such as not aspirating before administering a medication, the nurse should provide immediate, discreet feedback to correct the error. Walking up and whispering in the student's ear to stop, aspirate, and then inject is appropriate as it corrects the mistake while maintaining the student's dignity and confidence. Option A is not as effective as it indirectly addresses the issue. Option B is not the best approach as the student needs immediate correction. Option C is not ideal as loudly stating the mistake may embarrass the student and is not necessary for a discreet correction.

5. A client is prescribed a buccal medication. Which of the following client statements indicates that the client understands how to take this medication?

• A. “I will first dissolve the tablet in water.”
• B. “I will insert the tablet between my cheek and teeth.”
• C. “I will place the tablet under my tongue.”
• D. “I will chew the tablet.”

Correct answer: B

Rationale: The correct way to take buccal medications is to insert the tablet between the cheek and gums where it will dissolve slowly. Option A is incorrect because buccal medications are not meant to be dissolved in water. Option C is incorrect as sublingual medications are placed under the tongue. Option D is incorrect because chewing a buccal tablet is not the correct administration method.

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