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A client who is being treated for acute heart failure has the following vital signs: blood pressure (BP), 85/50 mm Hg; pulse, 96 beats per minute; respirations, 26 breaths per minute. The primary health care provider prescribes digoxin. To evaluate a therapeutic response to this medication, which changes in the client's vital signs should the nurse expect?
- A. BP 85/50 mm Hg, pulse 60 beats per minute, respirations 26 breaths per minute
- B. BP 98/60 mm Hg, pulse 80 beats per minute, respirations 24 breaths per minute
- C. BP 130/70 mm Hg, pulse 104 beats per minute, respirations 20 breaths per minute
- D. BP 110/40 mm Hg, pulse 110 beats per minute, respirations 20 breaths per minute
Correct Answer: B
Rationale: The main function of digoxin is inotropic. It produces increased myocardial contractility that is associated with an increased cardiac output. This causes a rise in the BP in a client with heart failure. Digoxin also has a negative chronotropic effect (decreases heart rate) and will therefore cause a slowing of the heart rate. As cardiac output improves, there should be an improvement in respirations as well. The remaining choices do not reflect the physiological changes attributed to this medication.
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The nurse is planning care for a client with a chest tube attached to a Pleur-Evac drainage system. The nurse should include which interventions in the plan? Select all that apply.
- A. Changing the client's position often
- B. Clamping the chest tube intermittently
- C. Maintaining the collection chamber below the client's waist
- D. Adding water to the suction control chamber as it evaporates
- E. Taping the connection between the chest tube and the drainage system
Correct Answer: A,C,D,E
Rationale: Changing the client's position frequently is necessary to promote drainage and ventilation. Maintaining the system below waist level is indicated to prevent fluid from reentering the pleural space. Adding water to the suction control chamber is an appropriate nursing action and is done as needed to maintain the full suction level prescribed. Taping the connection between the chest tube and system is also indicated to prevent accidental disconnection. To prevent a tension pneumothorax, the nurse avoids clamping the chest tube, unless specifically prescribed. In many facilities, clamping of the chest tube is contraindicated by agency policy.
A client is receiving desmopressin intranasally. Which assessment parameters should the nurse monitor to determine the effectiveness of this medication?
- A. Daily weight
- B. Temperature
- C. Apical heart rate
- D. Pupillary response
Correct Answer: A
Rationale: Desmopressin is an analog of vasopressin (antidiuretic hormone). It is used in the management of diabetes insipidus. The nurse monitors the client's fluid balance to determine the effectiveness of the medication. Fluid status can be evaluated by noting intake and urine output, daily weight, and the presence of edema. The measurements in options 2, 3, and 4 are not related to this medication.
A client prescribed warfarin sodium has been instructed to limit the intake of foods high in vitamin K. The nurse determines that the client understands the instructions if the client indicates that which food items need to be avoided? Select all that apply.
- A. Tea
- B. Turnips
- C. Oranges
- D. Cabbage
- E. Broccoli
- F. Strawberries
Correct Answer: A,B,D,E
Rationale: Warfarin sodium is an anticoagulant that interferes with the hepatic synthesis of vitamin K-dependent clotting factors. The client is instructed to limit the intake of foods high in vitamin K while taking this medication. These foods include coffee or tea (caffeine), turnips, cabbage, broccoli, greens, fish, and liver.
The nurse admits a client who is in sickle cell crisis. The nurse should prepare for which intervention as a priority in the management of the client?
- A. Pain management with an opioid
- B. Intravenous fluid therapy
- C. Oxygen administration
- D. Blood transfusion
Correct Answer: C
Rationale: The priority nursing intervention for a client in sickle cell crisis is to administer supplemental oxygen because the client is hypoxemic, and as a result, the red blood cells change to the sickle shape. In addition, oxygen is the priority because airway and breathing are more important than circulatory needs. The nurse also plans for fluid therapy to promote hydration and reverse the agglutination of sickled cells, opioid analgesics for relief from severe pain, and blood transfusions (rather than iron administration) to increase the blood's oxygen-carrying capacity.
The nurse creates a discharge plan for a client who had an abdominal hysterectomy. Which activity instructions should the nurse include in the plan? Select all that apply.
- A. Avoid heavy lifting.
- B. Sit as much as possible.
- C. Take baths rather than showers.
- D. Limit stair climbing to five times a day.
- E. Gradually increase walking as exercise but stop before becoming fatigued.
- F. Avoid jogging, aerobic exercises, sports, or any strenuous exercise for 6 weeks.
Correct Answer: A,D,E,F
Rationale: After abdominal hysterectomy, the client should avoid lifting anything that is heavy and limit stair climbing to five times a day. The client should walk indoors for the first week and then gradually increase walking as exercise, but stop before becoming fatigued. The client should avoid jogging, aerobic exercises, sports, or any strenuous exercise for 6 weeks. The client is also told to avoid the sitting position for extended periods, to take showers rather than tub baths, avoid crossing the legs at the knees, and avoid driving for at least 4 weeks or until the surgeon has given permission to do so.