Nokea
A client with heart failure has a prescription for Digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication
- A. can predispose to dysrhythmias
- B. may lead to oliguria
- C. may cause irritability and anxiety
- D. sometimes alters consciousness
Correct Answer: A
Rationale: can predispose to dysrhythmias. The nurse should be aware of a decrease in the client's potassium levels because low potassium enhances the effects of Digoxin and predisposes the client to dysrhythmias. The other options are seen in hyperkalemia. Muscle weakness occurs in both hyperkalemia and hypokalemia.
You may also like to solve these questions
The client who is receiving TPN through a subclavian triple-lumen catheter expresses concern to the nurse about bacteria entering the blood through the catheter. The nurse explains that the risk of catheter-related infections can be decreased by taking which action?
- A. Applying an antibiotic ointment at the catheter insertion site daily
- B. Changing the dressing over the catheter insertion site every day
- C. Designating one port of the catheter exclusively for the TPN solution
- D. Instilling an antibiotic solution daily into each port of the catheter
Correct Answer: C
Rationale: C: Using one port exclusively for TPN reduces infection risk by limiting access points. A, D: Antibiotic use risks resistance. B: Daily dressing changes are unnecessary unless soiled.
The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate?
- A. Decreased carbohydrates and fat
- B. Decreased sodium and potassium
- C. Increased potassium and protein
- D. Increased sodium and fluids
Correct Answer: B
Rationale: Decreased sodium and potassium. Children with AGN who have edema, hypertension, oliguria, and azotemia have dietary restrictions limiting sodium, potassium, fluids, and protein.
A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely?
- A. Bleeding time
- B. Hemoglobin and hematocrit
- C. White blood cells
- D. Platelets
Correct Answer: B
Rationale: Hemoglobin and hematocrit. The post-transfusion hematocrit provides immediate information about red cell replacement and about continued blood loss.
The HCP documents that the client has a generalized infection. Which specific assessment finding should the nurse expect?
- A. Redness and warmth at the site
- B. Swelling and pain at the site
- C. Hypertension and bradycardia
- D. Fever and widespread muscle aches
Correct Answer: D
Rationale: D: Generalized infections cause systemic symptoms like fever and muscle aches. A, B: These are localized signs. C: Hypotension and tachycardia are more likely.
The infection control nurse receives hospital laboratory confirmation that the client has positive sputum cultures for mycobacterium tuberculosis. Which action should be taken by the nurse?
- A. Prepare a statement for the hospital spokesperson to release to the news agencies
- B. Recommend that only staff with recent negative tuberculin skin tests provide care
- C. Implement measures to notify the local or state health department about the case
- D. Notify the nearest infectious disease facility and prepare the client for transfer
Correct Answer: C
Rationale: C: TB is a reportable disease, requiring health department notification. A: Media release is inappropriate. B: All staff can provide care with precautions. D: Transfer is unnecessary.