Nokea
A client with a history of heart failure is prescribed digoxin (Lanoxin). The nurse should instruct the client to:
- A. Report signs of toxicity.
- B. Take the medication with meals.
- C. Avoid potassium-rich foods.
- D. Stop the medication if pulse is above 100.
Correct Answer: A
Rationale: Reporting signs of digoxin toxicity (e.g., nausea, visual changes) is critical.
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The nurse caring for a client prescribed clozapine reviews the client's laboratory studies. Which laboratory study is the priority to monitor for an adverse effect associated with the use of this medication?
- A. Platelet count
- B. Cholesterol level
- C. Blood urea nitrogen
- D. White blood cell count
Correct Answer: D
Rationale: Hematological reactions can occur in the client taking clozapine, an atypical antipsychotic, and include agranulocytosis and mild leukopenia. The white blood cell count should be assessed before initiating treatment and should be monitored closely during the use of this medication. The client should also be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever. The remaining options are unrelated to the use of this medication.
Select the term which is most completely and accurately paired with its definition.
- A. A physical restraint: A physical restraint is a manufactured device that is used, when necessary, to prevent falls.
- B. A physical restraint: A physical restraint is any mechanical device, material, or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.
- C. A chemical restraint: A chemical restraint is a drug used for sedation to prevent falls.
- D. A chemical restraint: A chemical restraint is a drug used for discipline or convenience and not required to treat medical symptoms.
Correct Answer: B,D
Rationale: A physical restraint is correctly defined as a device restricting movement that the client cannot easily remove. A chemical restraint is a drug used for discipline or convenience, not for medical symptoms, such as preventing falls .
A client with a history of atrial fibrillation is admitted with a heart rate of 160 beats per minute. The nurse should prioritize which of the following interventions?
- A. Administer diltiazem as prescribed.
- B. Obtain a 12-lead ECG.
- C. Administer aspirin.
- D. Apply oxygen via nasal cannula.
Correct Answer: A
Rationale: Diltiazem, a calcium channel blocker, is prioritized to control rapid heart rate in atrial fibrillation.
The nurse is assessing a teenage girl. According to the fi gure below, the nurse should note that the girl has:
- A. Kyphosis.
- B. Arthritis.
- C. Developmental dysplasia of the hip.
- D. Scoliosis.
Correct Answer: D
Rationale: The teenage girl has scoliosis, the lateral deviation of the spine. Kyphosis is noted by a forward curvature of the shoulders. Arthritis is diagnosed by radiographs. Hip dysplasia is noted in older children by pain, but is usually diagnosed before the child walks by noting excessive gluteal folds and limited hip abduction.
When the nurse is assessing a client's cultural adaptation, which of the following statements is least sensitive to the client's needs?
- A. What are some of your favorite foods?'
- B. Describe any health problems in your past.'
- C. Please tell me how you would like to be addressed.'
- D. Your eyes look dark; is this normal for you?'
Correct Answer: D
Rationale: Commenting on the client's appearance (dark eyes) is insensitive and irrelevant to cultural adaptation, potentially making the client uncomfortable.