Nursing Elites

1. Which of the following findings contraindicate the use of haloperidol (Haldol) and warrant withholding the dose?

• A. Drowsiness, lethargy, and inactivity
• B. Dry mouth, nasal congestion, and blurred vision
• C. Rash, blood dyscrasias, severe depression
• D. Hyperglycemia, weight gain, and edema

Correct answer: C

Rationale: The correct answer is C: Rash, blood dyscrasias, and severe depression are serious side effects of haloperidol that necessitate withholding the dose and prompt further evaluation. Rash can indicate an allergic reaction, blood dyscrasias are serious blood disorders that can be life-threatening, and severe depression may worsen with haloperidol use. Choices A, B, and D are incorrect because drowsiness, lethargy, inactivity, dry mouth, nasal congestion, blurred vision, hyperglycemia, weight gain, and edema are common side effects of haloperidol that may not necessarily contraindicate its use but should be monitored and managed appropriately.

2. 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.

3. During a Weber test, what is an appropriate action for the nurse to take?

• A. Deliver a series of high-pitched sounds at random intervals.
• B. Place an activated tuning fork in the middle of the client's forehead.
• C. Hold an activated tuning fork against the client's mastoid process.
• D. Whisper a series of words softly into one ear.

Correct answer: B

Rationale: During a Weber test, the nurse should place an activated tuning fork in the middle of the client's forehead. This test is used to assess for lateralization of sound in a client with possible hearing issues. Choice A is incorrect because the Weber test does not involve delivering high-pitched sounds at random intervals. Choice C is incorrect as it describes the Rinne test, not the Weber test. Choice D is incorrect as whispering words into one ear is not part of the Weber test procedure.

4. A client with diabetes mellitus is being taught by a nurse about mixing regular and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should roll the NPH vial between my hands before drawing it up.
• B. I should draw up the NPH insulin before the regular insulin.
• C. I should inject air into the vial of regular insulin first.
• D. I should wait 10 minutes after mixing the insulin to inject it.

Correct answer: A

Rationale: The correct answer is A. Rolling the NPH vial between the hands before drawing it up ensures proper mixing of the insulin. Choice B is incorrect because regular insulin should be drawn up first to avoid contamination. Choice C is incorrect as injecting air into the vial of regular insulin is not necessary. Choice D is incorrect as there is no need to wait 10 minutes after mixing the insulin before injecting it.

5. The nurse is caring for a client with cirrhosis of the liver. Which finding should the LPN/LVN report to the healthcare provider immediately?

• A. Yellowing of the skin and eyes
• B. Dark-colored urine
• C. Abdominal distention
• D. Confusion

Correct answer: A

Rationale: Yellowing of the skin and eyes (jaundice) is a classic sign of liver dysfunction in clients with cirrhosis. Jaundice indicates the accumulation of bilirubin in the body due to impaired liver function. This finding suggests worsening liver damage and should be reported immediately to the healthcare provider for prompt evaluation and management. Dark-colored urine (choice B) is also a concerning symptom in liver disease, indicating possible bilirubin presence, but it is not as urgent as jaundice. Abdominal distention (choice C) and confusion (choice D) are common in cirrhosis but do not indicate an immediate need for healthcare provider notification compared to jajsondice.

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