Nokea
A client diagnosed with heart failure is receiving furosemide and digoxin daily. When the nurse enters the room to administer the morning doses, the client reports anorexia, nausea, and yellow vision. Which intervention should the nurse implement first?
- A. Administer the medications.
- B. Contact the primary health care provider.
- C. Check the morning serum digoxin level.
- D. Check the morning serum potassium level.
Correct Answer: C
Rationale: The nurse should check the result of the digoxin level that was drawn because the client's symptoms are compatible with digoxin toxicity. A low potassium level may contribute to digoxin toxicity, so checking the serum potassium level may give useful additional information, but the digoxin level should be checked first. The medications should be withheld until both levels are known. If the digoxin level is elevated or the potassium level is not within the normal range, then the primary health care provider should be notified. If the morning digoxin level is within the therapeutic range, then the client's complaints are unrelated to the digoxin.
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The nurse is caring for an infant diagnosed with laryngomalacia (congenital laryngeal stridor). In which position should the nurse place the infant to decrease the incidence of stridor?
- A. Prone
- B. Supine
- C. Supine with the neck flexed
- D. Prone with the neck hyperextended
Correct Answer: D
Rationale: The prone position with the neck hyperextended improves the child's breathing. Based on that information, none of the remaining options are appropriate positions.
A client in the second trimester of pregnancy is being assessed at the primary health care clinic. The nurse notes that the fetal heart rate (FHR) is 100 beats/min. Which nursing action would be appropriate initially?
- A. Document the findings as normal.
- B. Notify the primary health care provider of the finding.
- C. Inform the mother that the assessment is normal and everything is fine.
- D. Instruct the mother to return to the clinic in 8 hours for reevaluation of the FHR.
Correct Answer: B
Rationale: The FHR should be between 120 and 160 beats/min during pregnancy. An FHR of 100 beats/min would require that the primary health care provider be notified and the client be further evaluated. Although the nurse would document the findings, the most appropriate nursing action is to notify the primary health care provider. Based on this information, eliminate the options that suggest inaccurate nursing actions.
A mother of a child with mumps calls the health care clinic to tell the nurse that the child has been lethargic and vomiting. What instruction should the nurse give to the mother?
- A. To continue to monitor the child
- B. That lethargy and vomiting are normal manifestations of mumps
- C. To bring the child to the clinic to be seen by the primary health care provider
- D. That, as long as there is no fever, there is nothing to be concerned about
Correct Answer: C
Rationale: Mumps generally affects the salivary glands, but it can also affect multiple organs. The most common complication is septic meningitis, with the virus being identified in the cerebrospinal fluid. Common signs include nuchal rigidity, lethargy, and vomiting. The child should be seen by the primary health care provider.
A client admitted to the hospital with a diagnosis of a leaking cerebral aneurysm is scheduled for surgery. Which intervention should the nurse implement during the preoperative period?
- A. Place the client on bed rest.
- B. Allow the client to ambulate only in the room.
- C. Obtain a bedside commode for the client's use.
- D. Encourage the client to be up at least twice per day.
Correct Answer: A
Rationale: The client is placed on aneurysm precautions, and the client's activity is kept to a minimum to prevent Valsalva's maneuver. Clients often hold their breath and strain while pulling up to get out of bed. This exertion may cause a rise in blood pressure, which increases bleeding. Clients who have bleeding aneurysms in any vessel will have activity curtailed. Therefore, the rest of the options are incorrect actions.
Which action should the nurse implement as part of care for a client after a bone biopsy?
- A. Monitoring the vital signs once per day.
- B. Keeping the area in a dependent position.
- C. Administering intramuscular opioid analgesics.
- D. Monitoring the site for swelling, bleeding, or hematoma formation.
Correct Answer: D
Rationale: Nursing care after bone biopsy includes monitoring the site for swelling, bleeding, or hematoma formation. The vital signs are monitored every 4 hours for 24 hours. The biopsy site is elevated for 24 hours to reduce edema. A dependent position will increase the risk for bleeding. The client usually requires mild analgesics; more severe pain usually indicates that complications are arising.