Nokea
A client with a history of chronic heart failure is prescribed digoxin (Lanoxin). The nurse should monitor the client for which of the following signs of toxicity? Select all that apply.
- A. Nausea.
- B. Visual disturbances.
- C. Tachycardia.
- D. Fatigue.
- E. Hypokalemia.
Correct Answer: A, B, D
Rationale: Digoxin toxicity presents with nausea, visual disturbances (e.g., yellow vision), and fatigue. Hypokalemia increases toxicity risk but is not a symptom.
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A client has been taking furosemide (Lasix) for 2 days. The nurse should assess the client for:
- A. An elevated blood urea nitrogen (BUN) level.
- B. An elevated potassium level.
- C. A decreased potassium level.
- D. An elevated sodium level.
Correct Answer: C
Rationale: Furosemide, a loop diuretic, can cause hypokalemia, requiring assessment for decreased potassium levels.
When determining the parents' compliance with treatment for their child's ear infection, the nurse should ask the parents if they are:
- A. Cleaning the child's ear canals with hydrogen peroxide.
- B. Administering continuous, low-dose antibiotic therapy.
- C. Instilling ear drops regularly to prevent cerumen accumulation.
- D. Holding the child upright when feeding with a bottle.
Correct Answer: D
Rationale: Holding the child upright during feeding prevents milk from entering the Eustachian tube, reducing ear infection risk.
A client has begun medication therapy with pancrelipase. The nurse should educate the client to expect which occurrence from this medication?
- A. Relieve of heartburn
- B. Eliminate of abdominal pain
- C. Help regulating blood glucose
- D. Decrease in the amount of fat in the stools
Correct Answer: D
Rationale: Pancrelipase is a pancreatic enzyme used in clients with pancreatitis as a digestive aid. The medication should reduce the amount of fatty stools (steatorrhea). Another intended effect could be improved nutritional status. It is not used to treat abdominal pain or heartburn. It does not regulate blood glucose; this is a function of insulin, a hormone produced in the beta cells of the pancreas.
The nurse is teaching a client with a new diagnosis of epilepsy about self-care. Which of the following instructions should be included?
- A. Avoid swimming alone.
- B. Take medications at bedtime only.
- C. Limit fluid intake to prevent seizures.
- D. Wear loose-fitting clothing.
Correct Answer: A
Rationale: Avoiding swimming alone prevents drowning during a seizure, a key safety measure.
A 32-year-old woman recently diagnosed with Hodgkin's disease is admitted to the hospital outpatient clinic for staging by undergoing a bone marrow aspiration and biopsy. To obtain more information about the client's nutrition status the nurse should review the results of which of the following tests?
- A. Red blood cell count.
- B. Direct and indirect bilirubin levels.
- C. Reticulocyte count.
- D. Albumin level.
Correct Answer: D
Rationale: Albumin levels reflect nutritional status, as low levels indicate protein malnutrition, common in cancer patients. The other tests assess hematologic or liver function.