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A client with a diagnosis of chronic heart failure is receiving digoxin. What is the most important instruction the nurse should provide?
- A. Take the medication with a high-fiber meal
- B. Monitor pulse rate daily before taking the medication
- C. Avoid dairy products while on this medication
- D. Discontinue the medication if blurred vision is experienced
Correct Answer: B
Rationale: The most important instruction the nurse should provide is to monitor pulse rate daily before taking the medication. Digoxin can lead to bradycardia, so it is crucial to assess the pulse rate before administering the medication. This practice helps ensure that the heart rate is not too low for the safe use of digoxin. Choice A is incorrect as there is no specific requirement to take digoxin with a high-fiber meal. Choice C is also incorrect because there is no need to avoid dairy products while on digoxin. Choice D is incorrect since blurred vision is not a common side effect of digoxin; hence, it is not the most critical instruction to provide.
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The nurse is changing the colostomy bag for a client who is complaining of leakage of diarrheal stool under the disposable ostomy bag. What action should the nurse implement to prevent leakage?
- A. Place a 4x4 wick in the stoma opening
- B. Apply a layer of zinc oxide ointment to the perimeter of the stoma
- C. Cut the bag opening to the measurement of the stoma size
- D. Administer a PRN antidiarrheal agent
Correct Answer: C
Rationale: To prevent leakage of stool under the disposable ostomy bag, the nurse should cut the bag opening to the measurement of the stoma size. This action ensures a proper fit, which is crucial in preventing leaks that can lead to skin irritation and compromise stoma care. Placing a 4x4 wick in the stoma opening or applying zinc oxide ointment may not address the issue of leakage effectively. Administering a PRN antidiarrheal agent is not directly related to preventing leakage caused by an ill-fitting ostomy bag.
A client with a history of hypertension is admitted to the hospital for a suspected myocardial infarction. Which of the following is the priority nursing action?
- A. Administer oxygen as prescribed
- B. Perform an ECG
- C. Obtain a detailed health history
- D. Monitor vital signs regularly
Correct Answer: B
Rationale: The priority nursing action in this scenario is to perform an ECG. An ECG is crucial in confirming myocardial infarction promptly and guiding immediate treatment decisions. Administering oxygen as prescribed is important but not the priority over confirming the diagnosis. Obtaining a detailed health history is relevant but does not take precedence over immediate diagnostic confirmation. While monitoring vital signs regularly is essential, performing an ECG is the priority action in this scenario to guide timely management.
When caring for a client with a urinary catheter, what is the most important intervention to prevent infection?
- A. Use sterile technique for catheter care
- B. Ensure the catheter bag is below the level of the bladder
- C. Provide perineal care daily
- D. Change the catheter only when necessary
Correct Answer: B
Rationale: The most important intervention to prevent infection when caring for a client with a urinary catheter is to ensure that the catheter bag is below the level of the bladder. This positioning helps prevent urine backflow, reducing the risk of infection. While using sterile technique for catheter care (Choice A) is important, ensuring proper drainage by keeping the catheter bag below the bladder is crucial to prevent infection. Providing perineal care daily (Choice C) is essential for hygiene but not directly related to preventing catheter-related infections. Changing the catheter only when necessary (Choice D) is important for maintenance, but correct positioning of the catheter bag is more critical in preventing immediate infection.
The nurse is caring for a client who is scheduled for surgery in the morning. The client reports drinking a glass of water at midnight. What should the nurse do?
- A. Notify the anesthesiologist
- B. Document the intake in the medical record
- C. Cancel the surgery
- D. Instruct the client to fast until the surgery
Correct Answer: A
Rationale: The correct answer is to notify the anesthesiologist. When a client reports drinking water close to the time of surgery, it is important to inform the anesthesiologist as it can impact the administration of anesthesia. The anesthesiologist needs this information to make decisions regarding anesthesia administration. Documenting the intake in the medical record is important for documentation purposes, but the immediate action needed is to inform the anesthesiologist. Canceling the surgery is not necessary based solely on the intake of water; the anesthesiologist will determine the appropriate course of action. Instructing the client to fast until the surgery may not be appropriate without consulting the anesthesiologist first, as the situation needs to be assessed by the anesthesia team.
What skin care measure should the nurse implement for a client who underwent external radiation treatment the previous day?
- A. Cleanse the radiated area with water and pat the skin dry
- B. Lightly massage the radiated skin with a lanolin-based lotion
- C. Rinse the site with normal saline and cover with a sterile towel
- D. Use a soft washcloth to gently remove the skin markings
Correct Answer: A
Rationale: The correct measure for skin care after external radiation treatment is to cleanse the radiated area with water and pat the skin dry. This gentle cleansing without harsh chemicals or friction helps protect the integrity of radiated skin, preventing irritation or further damage. Choice B is incorrect because massaging radiated skin can cause further irritation, which should be avoided. Choice C is incorrect as rinsing with normal saline and covering with a sterile towel may not be necessary and could potentially introduce infection due to excessive moisture. Choice D is incorrect as using a soft washcloth to remove skin markings can be too abrasive for radiated skin, risking damage and irritation.