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A client with a history of congestive heart failure (CHF) is receiving digoxin (Lanoxin). The nurse should monitor the client for which sign of digoxin toxicity?
- A. Hypertension
- B. Bradycardia
- C. Hyperglycemia
- D. Insomnia
Correct Answer: B
Rationale: Bradycardia is a common sign of digoxin toxicity. Digoxin can cause bradycardia due to its effects on the heart's electrical conduction system. The nurse should closely monitor the client's heart rate for any signs of slowing down, as it can indicate toxicity and potentially lead to serious complications. Hypertension, hyperglycemia, and insomnia are not typically associated with digoxin toxicity. Hypertension is more commonly associated with other conditions or medications, hyperglycemia can be seen in conditions like diabetes or certain medications, and insomnia is not a typical sign of digoxin toxicity.
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A client with chronic obstructive pulmonary disease (COPD) is prescribed theophylline. Which adverse effect should the nurse monitor for that indicates toxicity?
- A. Tachycardia
- B. Constipation
- C. Drowsiness
- D. Tremors
Correct Answer: A
Rationale: The correct answer is A: Tachycardia. Tachycardia is a common sign of theophylline toxicity. The nurse should monitor the client for an increased heart rate, as it can indicate a dangerous level of theophylline in the body. Prompt medical attention is required if tachycardia is observed to prevent further complications. Choices B, C, and D are incorrect because constipation, drowsiness, and tremors are not typically associated with theophylline toxicity. While theophylline can cause gastrointestinal upset or central nervous system effects, tachycardia is a more specific and serious indicator of toxicity that requires immediate attention.
The client needs instruction on using a metered-dose inhaler (MDI). Which instruction should be given?
- A. Inhale the medication and then exhale immediately
- B. Exhale fully, then place the inhaler in your mouth and inhale deeply while pressing the canister
- C. Take two short breaths before inhaling the medication
- D. Hold your breath for 5 seconds after inhaling the medication
Correct Answer: B
Rationale: The correct technique for using a metered-dose inhaler (MDI) involves exhaling fully before inhaling deeply while pressing the canister to ensure effective delivery of the medication. Choice A is incorrect as exhaling should precede inhaling. Choice C is incorrect as taking two short breaths is not part of the correct technique. Choice D is incorrect as there is no need to hold the breath for a specific time after inhaling the medication.
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. The nurse listens to breath sounds, expecting to hear which breath sounds bilaterally?
- A. Rhonchi
- B. Crackles
- C. Wheezes
- D. Diminished breath sounds
Correct Answer: B
Rationale: In this scenario, the client is exhibiting signs of pulmonary edema, which can occur as a complication of myocardial infarction. Crackles are typically heard in cases of pulmonary edema, characterized by fluid accumulation in the lungs. These crackling sounds are heard during inspiration and sometimes expiration and are an indication of fluid-filled alveoli. Therefore, when assessing the client with these symptoms, the nurse would expect to hear crackles bilaterally. Rhonchi, which are coarse rattling respiratory sounds, are typically associated with conditions like bronchitis or pneumonia, not pulmonary edema. Wheezes are high-pitched musical sounds heard in conditions like asthma or COPD, not commonly present in pulmonary edema. Diminished breath sounds suggest decreased airflow or lung consolidation, not typical findings in pulmonary edema.
The client with heart failure is prescribed furosemide (Lasix). Which electrolyte imbalance is the nurse most likely to monitor for?
- A. Hyperkalemia
- B. Hypernatremia
- C. Hypokalemia
- D. Hyponatremia
Correct Answer: C
Rationale: The correct answer is C: Hypokalemia. Furosemide, a loop diuretic, commonly causes potassium loss, leading to hypokalemia. The nurse should closely monitor for decreased potassium levels in a client receiving furosemide to prevent complications such as cardiac arrhythmias or muscle weakness. Hyperkalemia (Choice A) is not typically associated with furosemide use. Hypernatremia (Choice B) refers to high sodium levels and is not the primary concern with furosemide. Hyponatremia (Choice D) is low sodium levels, which can occur but is less common than hypokalemia in clients taking furosemide.
The healthcare provider is monitoring a client following cardioversion. Which observation should be of the highest priority to the healthcare provider?
- A. Blood pressure
- B. Status of airway
- C. Oxygen flow rate
- D. Level of consciousness
Correct Answer: B
Rationale: The status of the airway is the highest priority following cardioversion as it ensures proper oxygenation and helps prevent complications such as airway obstruction and respiratory distress. Maintaining a patent airway is crucial for the client's respiratory function and overall well-being immediately after cardioversion. Monitoring the airway ensures that the client can breathe effectively and minimizes the risk of hypoxia and other serious respiratory issues. While blood pressure, oxygen flow rate, and level of consciousness are also important parameters to monitor, they are secondary to ensuring a clear and patent airway for adequate oxygenation.