The nurse is preparing to administer digoxin to a client with heart failure. Which finding requires holding the dose and notifying the physician?

Correct Answer: A

Rationale: Before digoxin in HF, a heart rate of 58 requires holding and notifying, not BP 130/80, K 4.0, or nausea. Digoxin slows HR below 60 risks toxicity, especially with nausea. BP and K are fine. Leadership checks this imagine bradycardia; it prevents arrest, aligning with cardiac care effectively.

Correct Answer: D

Rationale: Decentralized structures, Stephanie notes, favor flat, participatory, and shared governance models, not tall, centralized ones with many layers. In her hospital, flatness might mean nurses decide bedside, not wait for top orders, boosting responsiveness. Tall structures slow decisions, clashing with autonomy. Her leadership embraces this flexibility, key in a tertiary setting where quick, local action like adjusting care plans improves patient care, aligning with decentralized efficiency.

Correct Answer: B

Rationale: Administering medication via gastrostomy tube requires safety steps to ensure delivery and prevent complications. Flushing the tube with water before administration clears it, confirming patency and preventing clogs typically 15-30 mL per guidelines ensuring the drug reaches the stomach. Crushing an extended-release tablet alters its pharmacokinetics, risking overdose or inefficacy, contraindicated unless specified as crushable. Mixing with formula can cause interactions or clumping, impairing absorption, while skipping placement checks (e.g., aspirating gastric contents) risks misplacement into the lungs. Flushing first upholds medication safety principles, aligns with enteral administration standards, and protects the client from errors, critical in a route bypassing oral safeguards.

Correct Answer: D

Rationale: Discovering a double dose of antihypertensive medication requires prioritizing client safety using the nursing process assessment first. Checking the client's condition, including vital signs like blood pressure, is the initial action to determine the error's impact, as excessive antihypertensive can cause hypotension, risking organ perfusion. This data guides urgency and subsequent steps, like notifying the provider, who needs this information for orders. Completing an incident report is essential but secondary to assessing harm, and administering a reversal agent assumes effect without evidence, requiring a prescription anyway. Assessing first ensures the nurse responds proportionately escalating if critical or monitoring if stable aligning with ABC priorities and protecting the client from potential adverse outcomes of the error.

Correct Answer: B

Rationale: Highlighting shortcomings B is a trap. Nurse leaders overly focused here might dwell on errors, like a missed diagnosis, contrasting with balanced reflection. In healthcare, this can sap confidence, while awareness should build strengths, aligning leadership with constructive self-insight.

Correct Answer: A

Rationale: In an environmental disaster, discharge decisions prioritize stability and resource allocation. A client 1 day postoperative from an inguinal hernia repair is the best candidate, as this is a routine surgery with a low complication rate, and by day one, the client is typically stable, mobile, and manageable at home with basic instructions. A new diabetes diagnosis requires education and monitoring, risking instability if discharged prematurely. A client awaiting chemotherapy needs ongoing treatment, and a fresh hip replacement involves significant recovery challenges, both unsuitable for immediate discharge. The hernia client's condition aligns with disaster triage principles minimal ongoing care needs and low risk freeing up beds for disaster victims while ensuring safety, unlike the others whose conditions demand continued hospital oversight.

Correct Answer: C

Rationale: For an unconscious ventilated ED client, locating a medical alert tag is priority over jewelry, tampon, or patches. Tags reveal allergies or conditions say, diabetes affecting care, unlike accessories, tampons (unless toxic shock), or patches (less urgent). Leadership seeks this imagine an epinephrine reaction; a tag prevents errors, guiding treatment. This aligns nursing with rapid assessment, ensuring tailored, safe emergency care effectively.

Correct Answer: A

Rationale: When a client expresses uncertainty about a procedure despite signing a consent form, the nurse's responsibility is to reinforce the information previously provided by the provider. Reminding the client that the doctor will insert a needle to collect spinal fluid clarifies the process in a concise and factual manner, aligning with the nurse's role in ensuring informed consent. This action assumes the provider initially explained the procedure adequately, as indicated by the signed consent, but the client simply forgot the details. If the client still shows a lack of understanding or indicates the provider never informed her, further steps like notifying the charge nurse or provider would be necessary. However, the scenario suggests a memory lapse rather than a complete lack of prior explanation, making clarification the most appropriate initial response. This approach supports patient autonomy and ensures the client feels prepared without unnecessarily delaying the procedure or escalating the situation prematurely.

Correct Answer: C

Rationale: Pseudoephedrine works as a decongestant via vasoconstriction, not histamine block, antibacterial, or just BP rise. It shrinks nasal vessels, easing congestion BP may rise secondary, not primary. Leadership knows this imagine a stuffed-up patient; it clears airways, not infections. This reflects nursing's pharmacology grasp, guiding symptom relief in respiratory care effectively.