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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Discharge instructions for a client taking alprazolam (Xanax) should include which of the following?
- A. Sedative hypnotics are effective analgesics
- B. Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares
- C. Caffeine beverages can increase the effect of sedative hypnotics
- D. Avoidance of excessive exercise and high temperature is recommended
Correct Answer: B
Rationale: Sudden cessation of any medication, unless medically necessary, is ill-advised.
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.
The nurse is using contact precautions for the client with Clostridium difficile. While the nurse transfers the client from the bed to the commode, the client has loose stool that falls on the floor. After positioning the client on the commode, how should the nurse proceed to cleanse the floor?
- A. Wipe up the stool with toilet paper and then clean the area with soap and water
- B. Wipe up the stool with toilet paper and then clean the area with a 1:10 bleach-water solution
- C. Call housekeeping personnel to come clean the floor now with the unit's mop and bucket
- D. Wipe up the stool and apply the alcohol-based hand wash to cleanse the area of stool
Correct Answer: B
Rationale: B: Bleach solution effectively kills C. difficile spores. A: Soap and water are insufficient. C: Housekeeping delays action and risks spread. D: Alcohol is ineffective against C. difficile.
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.
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.