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A client has a new prescription for digoxin, and a nurse is providing teaching. Which of the following client statements indicates an understanding of the teaching?
- A. I will take my pulse before taking this medication.
- B. I will take this medication with an antacid.
- C. I will double the dose if I miss one.
- D. I will avoid eating bananas.
Correct Answer: A
Rationale: The correct answer is A because taking the pulse before administering digoxin is crucial as the medication can cause bradycardia. Monitoring the pulse helps in identifying any signs of bradycardia, a common side effect of digoxin. Options B, C, and D are incorrect. Taking digoxin with an antacid may interfere with its absorption. Doubling the dose if a dose is missed can lead to overdose and adverse effects. Avoiding bananas is not specifically related to digoxin therapy.
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What action should the nurse take to prevent aspiration in a client receiving enteral nutrition?
- A. Flush the feeding tube with water before and after feedings.
- B. Elevate the head of the bed to 30-45 degrees during feedings.
- C. Administer the feeding slowly.
- D. Check the client's weight daily.
Correct Answer: B
Rationale: Elevating the head of the bed to 30-45 degrees during feedings is essential to prevent aspiration in clients receiving enteral nutrition. This positioning helps decrease the risk of regurgitation and aspiration by supporting proper digestion and aiding food passage through the gastrointestinal tract. Elevating the head of the bed is a standard precautionary measure recommended to reduce the chances of aspiration and should be consistently implemented during feedings to ensure client safety and optimal enteral nutrition delivery.
What is the primary purpose of the Health Insurance Portability and Accountability Act (HIPAA)?
- A. To provide health insurance coverage for all Americans.
- B. To ensure the confidentiality of health information.
- C. To reduce the cost of healthcare.
- D. To increase access to healthcare services.
Correct Answer: B
Rationale: The primary purpose of the Health Insurance Portability and Accountability Act (HIPAA) is to ensure the confidentiality and security of health information. HIPAA establishes national standards to protect individuals' medical records and other personal health information. By safeguarding the privacy of health data, HIPAA aims to maintain the integrity and confidentiality of sensitive patient information, preventing unauthorized access and disclosure. This focus on privacy and security helps build trust between patients and healthcare providers, ensuring that personal health information is handled responsibly and ethically.
Which of the following techniques should be used to insert an indwelling urinary catheter for a female client?
- A. Use sterile technique.
- B. Insert the catheter 2-3 inches into the urethra.
- C. Inflate the balloon after insertion.
- D. Lubricate the catheter tip before insertion.
Correct Answer: D
Rationale: Lubricating the catheter tip before insertion is crucial for female urinary catheterization. This step helps reduce discomfort for the patient and facilitates smooth catheter insertion into the urethra. Using sterile technique maintains asepsis during the procedure, inserting the catheter 2-3 inches ensures proper placement, and inflating the balloon after insertion secures the catheter in place without causing trauma. Proper technique is fundamental for patient comfort, preventing infection, and ensuring the success of the catheterization procedure.
What action should the healthcare provider take for a patient with a chest tube?
- A. Strip the drainage tubing every 4 hours.
- B. Keep the drainage system below the level of the patient's chest.
- C. Clamp the chest tube when ambulating the patient.
- D. Ensure the water seal chamber is filled to the prescribed level.
Correct Answer: D
Rationale: Ensuring the water seal chamber is filled to the prescribed level is essential for the chest tube's effective functioning. This maintains the integrity of the system, prevents air from entering the pleural space, and facilitates proper drainage. Stripping the drainage tubing, keeping the drainage system below the chest level, or clamping the chest tube during ambulation are not recommended practices and can lead to complications.
A healthcare professional is preparing to insert an IV catheter for an older adult client. Which of the following actions should the professional take?
- A. Shave the hair at the insertion site.
- B. Insert the catheter at a 45-degree angle.
- C. Place the client's arm in a dependent position.
- D. Use a tourniquet to dilate the veins.
Correct Answer: C
Rationale: Placing the client's arm in a dependent position is the correct action when preparing to insert an IV catheter in an older adult client. This position helps dilate the veins naturally by using gravity, making it easier to locate and access suitable veins for the IV catheter insertion. By positioning the arm in a dependent position, the healthcare professional can take advantage of gravity to increase venous distention, aiding in successful IV catheter insertion.