Nokea
A client has been prescribed digoxin (Lanoxin). Which of the following symptoms should the nurse tell the client to report as a potential indication of digoxin toxicity?
- A. Urticaria.
- B. Shortness of breath.
- C. Visual disturbances.
- D. Hypertension.
Correct Answer: C
Rationale: Visual disturbances, such as blurred or yellow vision, are classic signs of digoxin toxicity, requiring immediate reporting.
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Which of the following clients is at greatest risk for extravasation?
- A. The client with heart failure who is receiving Ringer's lactate
- B. The client with cancer who is receiving bendamustine
- C. The client who is receiving potassium supplementation intravenously
- D. The client who is receiving total parenteral nutrition
Correct Answer: B
Rationale: Bendamustine, a chemotherapy drug, is a vesicant, posing a high risk for extravasation, which can cause severe tissue damage if it leaks into surrounding tissues.
A 24-year-old client has been diagnosed with acute osteomyelitis in the left leg. He complains of acute pain in the leg that intensifies when he moves it. The client has a temperature of 101°F (38.3°C) and a reddened, warm area in the midcalf region over the shaft of the tibia. Based on this information, which of the following nursing diagnoses would be most appropriate for this client?
- A. Grieving related to possible left lower leg amputation.
- B. Activity intolerance related to severe left leg pain.
- C. A disturbed body image related to left leg swelling and inflammation.
- D. Deficient fluid volume related to elevated temperature of 101°F (38.3°C).
Correct Answer: B
Rationale: Activity intolerance due to severe pain is the most appropriate diagnosis, as pain limits mobility. Amputation is not indicated, body image is secondary, and fever does not directly cause fluid volume deficit.
When assessing a 2-month-old infant, the nurse feels a 'click' when abducting the infant's left hip. Which of the following should the nurse do next?
- A. Document the finding as normal for a 2-month-old.
- B. Check the lengths of the femurs to determine if they are equal.
- C. Instruct the mother to keep the leg in an adducted position.
- D. Reschedule the child for a follow-up assessment in 3 weeks.
Correct Answer: B
Rationale: A 'click' during hip abduction suggests developmental dysplasia of the hip, so checking femur lengths helps confirm asymmetry for further evaluation.
While obtaining the vital signs on a mother who delivered a healthy newborn 2 hours ago the nurse notes that the mother's temperature is 102°F. Which is the appropriate nursing action at this time?
- A. Notify the primary health care provider.
- B. Remove the blanket from the client's bed.
- C. Document the finding and recheck the temperature in 4 hours.
- D. Administer acetaminophen and recheck the temperature in 4 hours.
Correct Answer: A
Rationale: Vital signs usually return to normal within the first hour postpartum if no complications arise. A slight elevation in the temperature may be noted if the client is experiencing dehydrating effects that can occur from labor. A temperature of 102°F indicates infection, and the primary health care provider should be notified. The remaining options are inaccurate nursing interventions for a temperature of 102°F 2 hours after delivery.
A client is being treated for severe pediculosis. The nurse should instruct the client to treat the problem in the eyebrows and eyelashes by:
- A. Applying petroleum jelly to lashes and brows three to four times a day.
- B. Applying a pediculicide with a cotton-tipped swab three to four times a day.
- C. Applying lindane ointment to the lashes and eyebrows three times a day.
- D. Applying bacitracin ointment to the lashes and brows three times a day.
Correct Answer: A
Rationale: Petroleum jelly smothers lice in the eyebrows and eyelashes, a safe and effective treatment for this sensitive area, unlike pediculicides or antibiotics.