Nokea
A client has had heart failure. Which intervention is most important for the nurse to implement prior to the initial administration of digoxin to this client?
- A. Assess the apical pulse, counting for a full 60 seconds
- B. Take a radial pulse, counting for a full 60 seconds
- C. Use the pulse reading from the electronic blood pressure device
- D. Check for a pulse deficit
Correct Answer: A
Rationale: Assess the apical pulse, counting for a full 60 seconds. It is the nurse’s responsibility to take the client’s pulse before administering digoxin. The correct technique for taking an apical pulse is to use the stethoscope and listen for a full 60 seconds. Digoxin is held for a pulse below 60 beats per minute. A radial pulse, potentially less accurate, or blood pressure are not part of the initial assessment before administering an initial dose of digoxin.
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The provider order reads 'Aspirate nasogastric (NG) feeding tube every 4 hours and check pH of aspirate.' The pH of the aspirate is 10. Which action should the nurse take?
- A. Hold the tube feeding and notify the provider
- B. Administer the tube feeding as scheduled
- C. Irrigate the tube with diet cola soda
- D. Apply intermittent suction to the feeding tube
Correct Answer: A
Rationale: Hold the tube feeding and notify the provider. A pH of less than 4 indicates that the tube is appropriately placed in the stomach, a highly acidic environment. A pH higher than 4 (alkaline pH) indicates intestinal placement.
A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse?
- A. Cut the child's hair short to remove the nits
- B. Apply warm soaks to the head twice daily
- C. Wash the child's linen and bedding in hot water
- D. Application of pediculicides
Correct Answer: D
Rationale: Application of pediculicides. Treatment of head lice consists of application of pediculicides. Pediculicides vary, and the directions must be followed carefully.
The nurse is caring for the client with a urinary catheter. Which interventions should the nurse implement to prevent a catheter-acquired UTI? Select all that apply.
- A. Rubbing for 10 seconds when using alcohol-based hand rubs
- B. Changing urinary catheters and drainage bags once a week
- C. Using the smallest numbered catheter with intermittent catheterizations
- D. Properly securing the catheter on the client's thigh to prevent movement
- E. Keeping a urinary drainage bag below the level of the client's bladder
Correct Answer: D,E
Rationale: D: Securing the catheter prevents urethral irritation, reducing UTI risk. E: Keeping the bag below bladder level prevents urine reflux. A: Hand rubs require 15-30 seconds. B: Routine changes increase risk. C: Larger catheters may be needed.
The client is admitted with a tentative diagnosis of hepatitis. The nurse determines that which client statement would be consistent with hepatitis?
- A. "I've not been sleeping well; I've heartburn at night that wakes me."
- B. "Whenever I eat dairy products I have diarrhea for a few days."
- C. "Lately I've been short of breath when walking short distances."
- D. "I am a smoker, but lately I can't tolerate the taste of cigarettes."
Correct Answer: D
Rationale: D: Distaste for cigarettes reflects anorexia, a common hepatitis symptom. A: Heartburn suggests GERD. B: Diarrhea with dairy indicates lactose intolerance. C: Shortness of breath is unrelated to hepatitis.
A man diagnosed with epididymitis 2 days ago calls the nurse at a health clinic to discuss the problem. What information is most important for the nurse to ask about at this time?
- A. What are you taking for pain and does it provide total relief?'
- B. Did your provider recommend that you be tested for Chlamydia?'
- C. Do you have any questions about your care?'
- D. Did you know a consequence of epididymitis is infertility?'
Correct Answer: B
Rationale: Did your provider recommend that you be tested for Chlamydia?' Epididymitis can result from Chlamydia infection, in which case the client's sexual partners should be tested as well. All of the questions should be asked, however, determining the reason for the client's referral is the most important to start with.