Nokea
A client with a history of heart failure is admitted with shortness of breath. The nurse should place the client in which of the following positions?
- A. Supine.
- B. Prone.
- C. Fowler's position.
- D. Trendelenburg position.
Correct Answer: C
Rationale: Fowler's position (semi-sitting) promotes lung expansion and reduces cardiac workload in heart failure clients with shortness of breath.
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The nurse monitors the serum electrolyte levels of a client who is taking digoxin (Lanoxin). Which of the following electrolyte imbalances is a common cause of digoxin toxicity?
- A. Hyponatremia.
- B. Hypomagnesemia.
- C. Hypocalcemia.
- D. Hypokalemia.
Correct Answer: D
Rationale: Hypokalemia enhances digoxin's effect on the heart, increasing toxicity risk by altering cardiac membrane potential.
The nurse should suspect that the client taking disulfiram (Antabuse) has ingested alcohol when the client exhibits which of the following symptoms?
- A. Sore throat and muscle aches.
- B. Nausea and flushing of the face and neck.
- C. Fever and muscle soreness.
- D. Bradycardia and vertigo.
Correct Answer: B
Rationale: Disulfiram causes an adverse reaction with alcohol, leading to symptoms like nausea and flushing due to acetaldehyde accumulation.
The most appropriate toys to give to a 5-month-old infant are:
- A. Plastic toy cars.
- B. Wooden puzzles.
- C. Stuffed animals.
- D. Soft, washable toys.
Correct Answer: D
Rationale: Soft, washable toys are safe and appropriate for a 5-month-old, who explores through touch and mouthing. Toy cars and puzzles are choking hazards, and stuffed animals may pose hygiene risks.
A young adult has been bitten by a human and the skin on the forearm is broken. The client's last tetanus shot was about 8 years ago. The nurse should prepare the client to receive:
- A. An injection of tetanus toxoid.
- B. An application of a corticosteroid cream.
- C. Closure of the wound with sutures.
- D. Testing for tuberculosis.
Correct Answer: A
Rationale: A human bite with broken skin and a tetanus shot over 5 years ago warrants tetanus toxoid to prevent tetanus infection. The other options are not indicated for this scenario.
The nurse is administering a dose of ondansetron hydrochloride to a client for nausea and vomiting. Which frequent side effect of this medication should the nurse instruct the client to report?
- A. Dizziness
- B. Blurred vision
- C. A warm feeling
- D. Urinary frequency
Correct Answer: A
Rationale: Ondansetron hydrochloride is a selective receptor antagonist used as an antinausea and antiemetic. Frequent side effects include anxiety, drowsiness, dizziness, headache, fatigue, constipation, diarrhea, urinary retention, and hypoxia. Occasional side effects include abdominal pain, diminished saliva secretion, fever, feeling cold, paresthesia, and weakness. Rare side effects include hypersensitivity reaction and blurred vision.