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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 healthcare professional is reviewing a client's medication prescription, which reads, 'digoxin 0.25 by mouth every day.' Which of the following components of the prescription should the healthcare professional question?
- A. the medication
- B. the route
- C. the dose
- D. the frequency
Correct Answer: C
Rationale: The healthcare professional should question the dose indicated in the prescription. In this case, '0.25' is incomplete without a unit of measurement, such as mg (milligrams). Without a specified unit, the dose lacks the necessary information for accurate administration. Choices A, B, and D are not incorrect components to question in medication prescriptions; however, in this scenario, the incompleteness of the dose is the most critical concern that needs clarification to ensure safe and effective medication administration.
A client with diabetes mellitus and a new prescription for insulin is being discharged. Which of the following actions should the nurse plan to complete first?
- A. Provide the client with printed information on insulin self-administration.
- B. Obtain printed information on insulin self-administration.
- C. Make a copy of the medication reconciliation form for the client.
- D. Determine whether the client can afford the insulin administration supplies.
Correct Answer: B
Rationale: Obtaining printed information on insulin self-administration should be the nurse's first priority. This action ensures that the client has the necessary knowledge to safely self-administer insulin at home. Providing the client with printed information (Choice A) is essential to empower the client with the required knowledge before considering additional resources. Making a copy of the medication reconciliation form for the client (Choice C) is important for documentation purposes but not as urgent as ensuring the client's understanding of insulin administration. Determining the client's ability to afford insulin administration supplies (Choice D) is crucial but should follow after ensuring the client is equipped with the necessary information for safe self-administration.
A nurse is preparing to insert an IV catheter for an adult client. Which of the following actions should the nurse take?
- A. Choose the most distal site on the selected extremity
- B. Apply a cool compress to the selected extremity before insertion of the IV catheter
- C. Stroke the selected extremity before insertion of the IV catheter
- D. Place the tourniquet above the proposed insertion site
Correct Answer: C
Rationale: When preparing to insert an IV catheter, stroking the extremity before insertion helps to visualize veins, making it easier to locate a suitable vein for catheter insertion. Choosing the most distal site on the extremity is correct because veins more distal are preferred for IV catheter insertion. Applying a cool compress to the extremity before insertion is unnecessary and not a standard practice. Placing the tourniquet below the proposed insertion site is incorrect; the tourniquet should be placed above the proposed insertion site to help engorge the veins for easier visualization and access.
When caring for a client with a tracheostomy, which of the following actions should the nurse take?
- A. Clean the skin around the stoma with normal saline.
- B. Secure the tracheostomy ties with two fingers' width underneath.
- C. Soak the outer cannula in warm tap water.
- D. Use a cotton tip applicator to clean the inside of the inner cannula.
Correct Answer: A
Rationale: When caring for a client with a tracheostomy, the nurse should clean the skin around the stoma with normal saline to prevent infection and ensure cleanliness. This action helps in maintaining skin integrity and preventing skin breakdown. Securing the tracheostomy ties with two fingers' width underneath is essential to allow for proper fit, prevent skin irritation, and ensure the ties are not too tight. Soaking the outer cannula in warm tap water is not recommended as it can lead to contamination and is not a standard practice. Using a cotton tip applicator to clean the inside of the inner cannula is discouraged as it can leave fibers behind, increasing the risk of aspiration and respiratory complications.
Which of the following manifestations confirms the presence of pediculosis capitis in students?
- A. Scratching the head more than usual
- B. Flakes evident on a student's shoulders
- C. Oval pattern occipital hair loss
- D. Whitish oval specks sticking to the hair
Correct Answer: D
Rationale: The correct answer is D. Whitish oval specks sticking to the hair shaft are nits, which are a definitive sign of pediculosis capitis (head lice). A: Scratching the head more than usual is a common symptom but not confirmatory of head lice infestation. B: Flakes evident on a student's shoulders may indicate dandruff or dry scalp, not necessarily head lice. C: Oval pattern occipital hair loss is not a typical manifestation of pediculosis capitis.