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 new nurse is caring for the client with a VRE infection. Which statement to the client indicates the new nurse needs additional orientation when caring for clients with a VRE infection?
- A. "All hospital staff should be wearing gown and gloves when they enter your room."
- B. "Visitors should use soap and water for hand washing when entering and leaving your room."
- C. "You are in a private room because VRE is transmitted by direct and indirect contact."
- D. "VRE is a new strain of enterococci bacteria normally found in a person's GI tract."
Correct Answer: A
Rationale: A: Gowns are only needed if clothing contamination is likely, indicating a need for further training. B, C, D: These statements are correct.
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.
An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be
- A. assess the severity and location of the pain
- B. obtain an order for an analgesic
- C. reassure him that this is not unusual for his age
- D. encourage him to increase his activity
Correct Answer: A
Rationale: assess the severity and location of the pain. Most older adults have 1 or more chronic painful illnesses, and in fact, they often must be asked about discomfort (rather than 'pain') to reveal the presence of pain. There is no evidence that pain of older adults is less intense, and it is necessary for the nurse to assess the pain thoroughly before implementing pain relief measures.
The nurse has been teaching a client with congestive heart failure about proper nutrition. Which of these lunch selections indicates the client has learned about sodium restriction?
- A. Cheese sandwich with a glass of 2% milk
- B. Sliced turkey sandwich and canned pineapple
- C. Cheeseburger and baked potato
- D. Mushroom pizza and ice cream
Correct Answer: B
Rationale: Sliced turkey sandwich and canned pineapple. Sliced turkey sandwich is appropriate since it is not a highly processed food and canned fruits are low in sodium. All of the other choices contain one or more high-sodium foods.
A client has returned from a cardiac catheterization. Which one of the following findings would indicate the client is experiencing a complication from the procedure?
- A. Increased blood pressure
- B. Increased heart rate
- C. Loss of pulse in the extremity
- D. Decreased urine output
Correct Answer: C
Rationale: Loss of pulse in the extremity. Loss of the pulse in the extremity would indicate impaired circulation.