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A client with a history of atrial fibrillation is taking digoxin (Lanoxin). Which finding should the healthcare provider be notified of immediately?
- A. Heart rate of 52 beats per minute
- B. Blood pressure of 110/70 mmHg
- C. Blood glucose level of 180 mg/dL
- D. Potassium level of 4.0 mEq/L
Correct Answer: A
Rationale: A heart rate of 52 beats per minute is a critical finding in a client taking digoxin, as it may indicate digoxin toxicity. Digoxin can cause bradycardia as a side effect, and a heart rate of 52 bpm warrants immediate attention to prevent adverse outcomes. Monitoring and reporting changes in heart rate are crucial in clients on digoxin therapy to prevent serious complications. The other vital signs and laboratory values provided are within normal ranges or not directly associated with digoxin toxicity in this scenario, making them lower priority for immediate reporting.
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A client with a history of seizures is prescribed phenytoin (Dilantin). Which statement should the LPN/LVN include when teaching the client about this medication?
- A. Do not take the medication with milk to avoid reduced absorption.
- B. Brush and floss your teeth regularly to prevent gum disease.
- C. Avoid taking antacids within 2 hours of the medication.
- D. Report any unusual bleeding or bruising to the healthcare provider.
Correct Answer: C
Rationale: The correct answer is to avoid taking antacids within 2 hours of phenytoin. Antacids can interfere with the absorption of phenytoin, reducing its effectiveness. Choice A is incorrect because phenytoin should not be taken with milk, as it may decrease its absorption. Choice B is unrelated to the medication and focuses on dental hygiene. Choice D is important but not directly related to phenytoin; it is more relevant to monitoring for adverse effects of the medication.
A healthcare professional is instructing an AP about caring for a client who has a low platelet count. Which of the following instructions is the priority for measuring vital signs for this client?
- A. Avoid measuring the client's temperature rectally.
- B. Count the client's radial pulse for 30 seconds and multiply it by 2.
- C. Count the client's respirations discreetly.
- D. Allow the client to rest for 5 minutes before measuring their BP.
Correct Answer: A
Rationale: The correct answer is to avoid measuring the client's temperature rectally. Rectal temperatures can cause bleeding in clients with low platelet counts. It is crucial to avoid invasive methods that could increase the risk of bleeding or discomfort. Choice B, counting the radial pulse, is not directly related to the risk of bleeding in a client with low platelet count. Choice C, counting respirations discreetly, is important for accuracy but is not the priority when considering the risk of bleeding. Choice D, letting the client rest before measuring blood pressure, is beneficial but is not the priority in preventing potential harm due to low platelet counts.
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?
- A. Obtaining cotton balls for the tracheostomy care
- B. Using a sterile water bottle
- C. Checking the suction equipment
- D. Wearing a sterile gown
Correct Answer: A
Rationale: The correct answer is A. Obtaining cotton balls for tracheostomy care is not recommended due to the risk of fiber contamination. Sterile gauze should be used instead. Choice B, using a sterile water bottle, is a correct and appropriate action for tracheostomy care to maintain cleanliness. Choice C, checking the suction equipment, is also a necessary step to ensure it is functioning properly for the procedure. Choice D, wearing a sterile gown, is a standard precaution to maintain a sterile environment during tracheostomy care.
A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing?
- A. Assault
- B. Battery
- C. False imprisonment
- D. Invasion of privacy
Correct Answer: A
Rationale: The correct answer is A: Assault. Assault involves making threats or using actions that cause the client to fear harm. In this scenario, the AP's threat to use diapers next time the urinal is used improperly constitutes as assault. Choice B, Battery, involves intentional harmful or offensive touching without consent, which is not evident in the scenario. Choice C, False imprisonment, refers to restraining or restricting a client's freedom of movement, which is not occurring in this situation. Choice D, Invasion of privacy, involves violating a client's right to privacy, which is also not applicable here.
During a mass casualty event, a nurse is caring for multiple clients. Which of the following clients is the nurse's priority?
- A. A client who received crush injuries to the chest and abdomen and is expected to die.
- B. A client who has a 4-inch laceration to the head.
- C. A client who has partial-thickness and full-thickness burns to his face, neck, and chest.
- D. A client who has a fractured fibula and tibia.
Correct Answer: C
Rationale: During a mass casualty event, the priority client for the nurse is the one with partial-thickness and full-thickness burns to the face, neck, and chest. Clients with severe burns in critical areas require immediate attention due to the potential for life-threatening complications such as airway compromise, fluid loss, and infection. Crush injuries and fractures, although serious, are generally less urgent in comparison and can be managed after addressing the burns. Therefore, the client with burns to the face, neck, and chest should be the nurse's priority over the other clients described.