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A 68-year-old client was admitted with congestive heart failure, has been digitalized, and is now taking a maintenance dose of digoxin 0.25 mg PO daily. The client is to be discharged soon. Which assessment is of most immediate concern to the nurse?
- A. The client's apical pulse is 66.
- B. The client says that he is nauseous and has no appetite.
- C. The client says that he will take his pill every morning.
- D. The client has lost 8 lb since his admission one week ago.
Correct Answer: B
Rationale: Nausea and anorexia are signs of digoxin toxicity, requiring immediate attention to prevent serious complications.
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The nurse is providing education for a client with newly diagnosed tuberculosis. Which statement should be included in the information that is given to the client?
- A. Isolate yourself from others until you are finished taking your medication.'
- B. Follow up with your primary care provider in 3 months.'
- C. Continue to take your medications even when you are feeling fine.'
- D. Continue to get yearly tuberculin skin tests.'
Correct Answer: C
Rationale: The most important piece of information the tuberculosis client needs is to understand the importance of medication compliance, even if no longer experiencing symptoms. Clients are most infectious early in the course of therapy. The numbers of acid-fast bacilli are greatly reduced as early as 2 weeks after therapy begins.
To which client would the nurse question administering the osmotic diuretic mannitol (Osmitrol)?
- A. The client with 4+ pitting pedal edema.
- B. The client with decorticate posturing.
- C. The client with widening pulse pressure.
- D. The client with a positive doll's eye test.
Correct Answer: C
Rationale: Widening pulse pressure suggests increased intracranial pressure, a contraindication for mannitol due to potential brain herniation. Edema or neurological signs are indications.
The nurse is administering diltiazem (Cardizem) to a client. Prior to administration, it is important for the nurse to assess which parameter?
- A. Temperature
- B. Blood pressure
- C. Vision
- D. Bowel sounds
Correct Answer: B
Rationale: Blood pressure. Diltiazem (Cardizem) is a calcium channel blocker that causes systemic vasodilation resulting in decreased blood pressure.
The nurse is assessing the elderly client first thing in the morning. The client is confused and sleepy. Which intervention should the nurse implement first?
- A. Determine if the client received a sedative last night.
- B. Allow the client to continue to sleep and do not disturb.
- C. Encourage the client to ambulate in the room with assistance.
- D. Notify the health-care provider about the client's status.
Correct Answer: A
Rationale: Sedatives are a common cause of morning confusion in the elderly; determining recent administration guides next steps.
The client is diagnosed with pernicious anemia. Which health-care provider order should the nurse anticipate in treating this condition?
- A. Subcutaneous iron dextran.
- B. Intramuscular vitamin B12.
- C. Intravenous folic acid.
- D. Oral thiamine medication.
Correct Answer: B
Rationale: Pernicious anemia results from B12 deficiency; IM B12 is standard treatment due to absorption issues. Iron, folic acid, or thiamine do not address the primary cause.