Nokea
A client with atrial fibrillation is prescribed digoxin (Lanoxin). Which finding indicates a potential toxicity?
- A. Heart rate of 80 bpm.
- B. Visual disturbances.
- C. Blood pressure of 120/80 mm Hg.
- D. Clear lung sounds.
Correct Answer: B
Rationale: Visual disturbances, such as blurred or yellow vision, are classic signs of digoxin toxicity, requiring immediate reporting.
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The nurse is preparing to administer a dose of warfarin (Coumadin) to a client. The client's International Normalized Ratio (INR) is 4.0. What should the nurse do?
- A. Administer the dose as ordered.
- B. Hold the dose and notify the physician.
- C. Administer half the prescribed dose.
- D. Administer vitamin K as an antidote.
Correct Answer: B
Rationale: An INR of 4.0 is above the therapeutic range (2-3), indicating a risk of bleeding, so the nurse should hold the dose and notify the physician.
The nurse is caring for a client who has just undergone a splenectomy. Which of the following complications should the nurse monitor for in the immediate postoperative period?
- A. Infection.
- B. Hypoglycemia.
- C. Hypertension.
- D. Weight loss.
Correct Answer: A
Rationale: Splenectomy increases infection risk due to impaired immune function, requiring close monitoring.
Mebendazole (Vermox) is prescribed for an 8-year-old child with pinworms. The child has an 18-month-old brother and a 4-year-old sister. The nurse should be sure that the parents are also treating which of the following family members with this drug?
- A. Both of the child's siblings
- B. The child's parents and brother
- C. Everyone who lives in the household
- D. The parents and sister
Correct Answer: C
Rationale: Pinworms are highly contagious, so all household members should be treated with mebendazole to prevent reinfection, regardless of symptoms.
The nurse is administering eyedrops to a client with glaucoma. Which of the following is a correct technique for instilling the eyedrops? The eyedrops are placed:
- A. In the lower conjunctival sac.
- B. Near the opening of the lacrimal ducts.
- C. On the cornea.
- D. On the scleral surface.
Correct Answer: A
Rationale: Placing eyedrops in the lower conjunctival sac ensures proper absorption and minimizes irritation or injury to the cornea or sclera.
A client is hospitalized for ingesting an overdose of acetaminophen. The nurse prepares to administer which specific antidote for this medication overdose?
- A. Flumazenil
- B. Phytonadione
- C. N-acetylcysteine
- D. Naloxone hydrochloride
Correct Answer: C
Rationale: Acetylcysteine restores sulfhydryl groups that are depleted by acetaminophen metabolism. Flumazenil is the antidote for benzodiazepine reversal. Phytonadione is the antidote for warfarin sodium. Naloxone hydrochloride reverses respiratory depression caused by an opioid.