Nokea
A 6-month-old infant is prescribed digoxin for the treatment of congestive heart failure. Which observation by the practical nurse (PN) warrants immediate intervention for signs of digoxin toxicity?
- A. Apical heart rate of 60 beats/min
- B. Sweating across the forehead
- C. Poor sucking effort
- D. Respiratory rate of 30 breaths/min
Correct Answer: A
Rationale: A heart rate of 60 beats/min for a 6-month-old infant warrants immediate intervention as it falls below the normal range. The normal heart rate for a 6-month-old is 80 to 150 beats/min when awake, and a rate of 70 beats/min while sleeping is considered within normal limits. Bradycardia (heart rate <60 beats/min) in infants can be a sign of digoxin toxicity, necessitating prompt evaluation and intervention to prevent adverse effects.
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A client undergoing hemodialysis for chronic kidney disease is taking the medication erythropoietin. The nurse should reinforce instructions to explain for which reason this medication is prescribed?
- A. This drug prevents infections associated with dialysis.
- B. This drug prevents deep vein thrombosis in older clients.
- C. This drug helps stimulate the production of red blood cells.
- D. This drug helps balance the level of phosphorus in the body.
Correct Answer: C
Rationale: Erythropoietin is prescribed to stimulate the production of red blood cells. Clients undergoing hemodialysis often develop anemia due to end-stage renal disease. Erythropoietin helps in correcting this anemia by stimulating red blood cell production. It is not used to prevent infections associated with dialysis, deep vein thrombosis, or to balance phosphorus levels in the body.
A healthcare professional prepares to administer a scheduled dose of labetalol by mouth to a client with hypertension. The client's heart rate is 48 beats/min, respirations are 16 breaths/min, and blood pressure is 150/90 mmHg.
- A. Administer the dose and monitor the client's blood pressure regularly
- B. Apply a telemetry monitor before administering the dose
- C. Assess for orthostatic hypotension before administering the dose
- D. Withhold the scheduled dose and notify the healthcare provider
Correct Answer: D
Rationale: The client's low heart rate of 48 beats/min indicates bradycardia, a potential side effect of labetalol. Administering the dose in this case could further lower the heart rate, potentially causing adverse effects. Therefore, it is crucial to withhold the scheduled dose and notify the healthcare provider for further assessment and guidance.
A client is taking levodopa-carbidopa for Parkinson's disease. The nurse should include which instruction when educating the client about this medication?
- A. Increase fluid intake to prevent dehydration.
- B. Take medication at bedtime to avoid daytime drowsiness.
- C. Take medication with food to improve absorption.
- D. It can cause nausea and dizziness.
Correct Answer: A
Rationale: The correct instruction for a client taking levodopa-carbidopa for Parkinson's disease is to increase fluid intake to prevent dehydration. Levodopa-carbidopa should be taken with food to reduce gastrointestinal upset and improve absorption. Taking medication at bedtime is not necessary to avoid daytime drowsiness, and it is essential to prevent dehydration due to the medication's side effects.
A client with a history of deep vein thrombosis is prescribed fondaparinux. The nurse should monitor for which potential adverse effect?
- A. Increased risk of bleeding
- B. Decreased risk of bleeding
- C. Increased risk of infection
- D. Decreased risk of infection
Correct Answer: A
Rationale: Corrected Question: When a client with a history of deep vein thrombosis is prescribed fondaparinux, the nurse should monitor for the potential adverse effect of an increased risk of bleeding. Fondaparinux is an anticoagulant that works by preventing blood clots, which can lead to an increased risk of bleeding. Therefore, the nurse should closely monitor the client for signs of bleeding, such as unexplained bruising, bleeding gums, or blood in the urine or stool.
A client with a history of atrial fibrillation is prescribed sotalol. The nurse should monitor for which potential side effect?
- A. Bradycardia
- B. Tachycardia
- C. Headache
- D. Hyperglycemia
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.