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A client has a history of heart failure and has been taking several medications, including furosemide (Lasix), digoxin (Lanoxin) and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first-degree atrioventricular block. The nurse should assess the client for signs of which condition?
- A. Hyperkalemia.
- B. Digoxin toxicity.
- C. Fluid deficit.
- D. Pulmonary edema.
Correct Answer: B
Rationale: Nausea, blurred vision, confusion, and AV block are classic signs of digoxin toxicity, especially in a client taking digoxin, requiring immediate assessment.
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A client is receiving vincristine (Oncovin). Client teaching by the nurse should include instructions on:
- A. Use of loperamide (Imodium).
- B. Fluid restriction.
- C. Low fiber, bland diet.
- D. Bowel regimen.
Correct Answer: D
Rationale: Vincristine commonly causes constipation due to neurotoxicity. A bowel regimen (e.g., stool softeners, laxatives) is essential to prevent and manage this side effect.
A new medication regimen is ordered for a client with Parkinson's disease. At which time should the nurse make certain that the medication is taken?
- A. At bedtime.
- B. All at one time.
- C. Two hours before mealtime.
- D. At the time scheduled.
Correct Answer: D
Rationale: Adhering to the scheduled times ensures consistent drug levels, critical for managing Parkinson's symptoms. Bedtime, single dosing, or pre-meal timing may disrupt therapeutic efficacy.
After the initial phase of the burn injury, the client's plan of care will focus primarily on:
- A. Helping the client maintain a positive selfconcept.
- B. Promoting hygiene.
- C. Everything infection.
- D. Educating the client regarding care of the skin grafts.
Correct Answer: C
Rationale: Infection prevention is critical in the acute phase of burn care, as burns compromise the skin's barrier, increasing infection risk. Other options are secondary priorities.
The client's blood urea nitrogen (BUN) concentration is elevated in acute renal failure. What is the likely cause of this finding?
- A. Fluid retention.
- B. Hemolysis of red blood cells.
- C. Below-normal metabolic rate.
- D. Reduced renal blood flow.
Correct Answer: D
Rationale: Reduced renal blood flow impairs urea excretion, causing elevated BUN levels in acute renal failure.
The nurse is assessing a client with a cast for compartment syndrome. Which finding is most indicative?
- A. Pain relieved by elevation.
- B. Numbness in the affected limb.
- C. Warm skin over the cast.
- D. Visible swelling at the cast edge.
Correct Answer: B
Rationale: Numbness is a key sign of compartment syndrome, indicating nerve compression requiring urgent intervention.