Nokea
A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug?
- A. Diaphoresis with decreased urinary output
- B. Increased heart rate with increased respirations
- C. Improved respiratory status and increased urinary output
- D. Decreased chest pain and decreased blood pressure
Correct Answer: C
Rationale: Improved respiratory status and increased urinary output. Digoxin, a cardiac glycoside, is used in clients with heart failure to slow and strengthen the heartbeat. As cardiac output is improved, renal perfusion is improved and urinary output increases. Clients can become toxic on this drug, indicated by findings of bradycardia, dysrhythmia, and visual and GI disturbances.
You may also like to solve these questions
The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take?
- A. Stop the infusion
- B. Slow the rate of infusion
- C. Take vital signs and observe for further deterioration
- D. Administer Benadryl and continue the infusion
Correct Answer: A
Rationale: Stop the infusion. This is an indication of an allergy to the plasma protein. The priority action of the nurse is to stop the transfusion.
A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin?
- A. Protamine
- B. Amicar
- C. Imferon
- D. Diltiazem
Correct Answer: A
Rationale: Protamine. Protamine binds heparin, making it ineffective.
A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Addressing which of the following should take priority in planning care?
- A. Esophagitis
- B. Leukopenia
- C. Fatigue
- D. Skin irritation
Correct Answer: B
Rationale: Leukopenia. Clients develop leukopenia due to the depressant effect of radiation therapy on bone marrow function. Infection is the most frequent cause of morbidity and death in clients with cancer.
The nurse is assessing an 8 month-old child with atonic cerebral palsy. Which statement from the parent supports the presence of this problem?
- A. When I put my finger in the left hand the baby doesn't respond with a grasp.'
- B. My baby doesn't seem to follow when I shake toys in front of its face.'
- C. When it thundered loudly last night the baby didn't even jump.'
- D. When I put the baby in a back lying position that's how I find it hours later.'
Correct Answer: D
Rationale: When I put the baby in a back lying position that's how I find it hours later.' Atonic cerebral palsy is characterized by low muscle tone and lack of movement, so the baby remaining in the same position for hours supports this diagnosis.
Which information is most important for the nurse to reinforce with a male client who is about to undergo a vasectomy?
- A. Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception.'
- B. This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate.'
- C. After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you may return to work as soon as you feel up to it.'
- D. The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort.'
Correct Answer: A
Rationale: All of these options are correct information. The most important point to reinforce is the continuing need to take additional action for birth control until the absence of sperm in the ejaculate is confirmed.