Nokea
A client has a prescription for digoxin. Which of the following instructions should the nurse include?
- A. Take this medication with food.
- B. Avoid taking antacids at the same time as this medication.
- C. Take this medication if your heart rate is above 100/min.
- D. Notify your provider if you experience nausea or visual changes.
Correct Answer: D
Rationale: The correct instruction the nurse should include for a client prescribed digoxin is to notify the provider if they experience nausea or visual changes, as these symptoms can indicate digoxin toxicity. Option A is incorrect because digoxin should be taken on an empty stomach for better absorption. Option B is incorrect as antacids can interfere with the absorption of digoxin. Option C is incorrect as taking digoxin based on heart rate alone is not appropriate.
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A nurse is caring for a client who has a prescription for a high-protein diet to promote wound healing. Which of the following foods should the nurse recommend?
- A. Bananas
- B. Fish
- C. White bread
- D. Chicken breast
Correct Answer: D
Rationale: Corrected Rationale: Chicken breast is an excellent source of protein, which is essential for wound healing due to its role in tissue repair and regeneration. Fish is also a good source of protein, but chicken breast is a more commonly recommended option for wound healing due to its high protein content and lower fat content compared to some types of fish. Bananas and white bread, on the other hand, are not high-protein foods and do not provide the necessary nutrients for wound healing.
A healthcare provider is reviewing the laboratory data of a client who is receiving total parenteral nutrition. Which of the following findings should the healthcare provider report?
- A. Serum calcium 8.5 mg/dL
- B. Blood glucose level 120 mg/dL
- C. Serum sodium 138 mEq/L
- D. Serum albumin 3.5 g/dL
Correct Answer: D
Rationale: The correct answer is D: Serum albumin 3.5 g/dL. A low serum albumin level indicates protein deficiency, which can be a complication of TPN therapy and requires prompt intervention. The other laboratory findings provided (serum calcium 8.5 mg/dL, blood glucose level 120 mg/dL, and serum sodium 138 mEq/L) are within normal ranges and do not specifically indicate complications related to TPN therapy.
How should fluid balance be assessed in a patient with heart failure?
- A. Monitor daily weight
- B. Monitor input and output
- C. Check for edema
- D. Monitor blood pressure
Correct Answer: A
Rationale: In patients with heart failure, monitoring daily weight is the most accurate method for assessing fluid balance. Weight gain can indicate fluid retention, a common issue in heart failure patients. Monitoring input and output (B) is essential but may not always accurately reflect fluid balance. Checking for edema (C) is important as it can indicate fluid accumulation, but daily weight monitoring is more precise. Monitoring blood pressure (D) is important in heart failure management but does not directly assess fluid balance.
A patient is diagnosed with deep vein thrombosis (DVT). Which of the following actions should the nurse take?
- A. Massage the affected extremity every 2 hours.
- B. Encourage the patient to ambulate as soon as possible.
- C. Apply warm compresses to the affected extremity.
- D. Elevate the affected extremity.
Correct Answer: D
Rationale: Elevating the affected extremity is crucial in managing deep vein thrombosis (DVT) as it helps reduce swelling and promotes venous return, thereby preventing further complications such as pulmonary embolism. Massaging the affected extremity can dislodge a clot and lead to serious consequences. While ambulation is important, in DVT, early ambulation without elevation can potentially dislodge the clot. Warm compresses can increase blood flow to the area and worsen the condition by promoting clot dislodgement.
What is the best nursing intervention for a patient experiencing fluid overload?
- A. Administer diuretics
- B. Administer IV fluids
- C. Provide oral fluids
- D. Provide chest physiotherapy
Correct Answer: A
Rationale: The best nursing intervention for a patient experiencing fluid overload is to administer diuretics. Diuretics help the body to remove excess fluid by increasing urine output. This intervention is crucial in managing fluid overload. Administering IV fluids (Choice B) would worsen the condition by adding more fluids to the already overloaded system. Providing oral fluids (Choice C) is not appropriate as it would further contribute to the fluid overload. Chest physiotherapy (Choice D) is not indicated in the treatment of fluid overload and would not address the underlying issue of excess fluid accumulation.