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A client with a history of heart failure is prescribed spironolactone (Aldactone). The nurse should instruct the client to:
- A. Avoid potassium-rich foods.
- B. Take the medication at bedtime.
- C. Monitor blood pressure regularly.
- D. Stop the medication if dizziness occurs.
Correct Answer: A, C
Rationale: Spironolactone can cause hyperkalemia, requiring avoidance of potassium-rich foods, and blood pressure monitoring for hypotension.
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A 6-year-old child is admitted to the hospital for heart surgery to repair tetralogy of Fallot. The child asks the nurse if the cardiac catheterization will hurt. Which of the following statements offers the nurse the best guide for responding to the child's question?
- A. The medication used to numb the insertion site will sting
- B. Momentary sharp pain usually occurs when the catheter enters the heart
- C. It is usual for a 6-year-old to feel discomfort during the procedure
- D. It is a painless procedure, although a tingling sensation may be felt in the extremities
Correct Answer: A
Rationale: The local anesthetic used at the insertion site for cardiac catheterization may cause a stinging sensation, which is an honest and appropriate response for a 6-year-old. Pain is not typically felt when the catheter enters the heart, and discomfort or tingling is not a standard experience.
The nurse is caring for a client with a new tracheostomy. Which action is the priority during routine care?
- A. Suction the tracheostomy every 4 hours.
- B. Clean the stoma site with sterile saline.
- C. Change the tracheostomy ties daily.
- D. Monitor for signs of infection.
Correct Answer: B
Rationale: Cleaning the stoma site with sterile saline prevents infection and maintains skin integrity, making it the priority during routine tracheostomy care.
A client with a history of myocardial infarction is prescribed aspirin. What is the primary purpose of this medication?
- A. Reduce fever.
- B. Prevent platelet aggregation.
- C. Relieve chest pain.
- D. Lower cholesterol.
Correct Answer: B
Rationale: Aspirin prevents platelet aggregation, reducing the risk of thrombus formation in clients with a history of myocardial infarction.
You are the registered nurse in a multi ethnic community health department clinic. In this role you are asked to identify clients who have genetic risk factors related to ethnicity in order to screen them for some commonly occurring diseases and disorders. You would identify a client who is of:
- A. Mediterranean ethnicity for cystic fibrosis.
- B. African American ethnicity for Tay Sachs disease.
- C. British Isles ethnicity for psychiatric mental health disorders.
- D. Saudi Arabian ethnicity for sickle cell anemia.
Correct Answer: D
Rationale: Sickle cell anemia is strongly associated with populations from regions like Saudi Arabia, Africa, and parts of India. Screening clients of Saudi Arabian ethnicity for sickle cell anemia is appropriate due to the higher prevalence of the sickle cell trait in these populations.
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.