Nokea
A client with heart failure is prescribed digoxin (Lanoxin). Which instruction should the nurse include in the client's teaching plan?
- A. Take your pulse before each dose and hold the medication if your pulse is below 60 beats per minute.
- B. Increase your intake of foods high in potassium.
- C. Take the medication with a high-fiber meal to enhance absorption.
- D. Skip a dose if you feel dizzy or lightheaded.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Digoxin is a medication that can cause bradycardia as a side effect.
2. Instructing the client to take their pulse before each dose is crucial to monitor for bradycardia.
3. Holding the medication if the pulse is below 60 beats per minute helps prevent potential adverse effects.
4. This instruction ensures the client's safety and adherence to the prescribed regimen.
Summary:
- Choice B is incorrect because increasing potassium intake can lead to hyperkalemia when taking digoxin.
- Choice C is incorrect as taking digoxin with a high-fiber meal may affect absorption negatively.
- Choice D is incorrect because skipping a dose based on dizziness or lightheadedness may lead to suboptimal treatment outcomes.
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A client with a history of peptic ulcer disease is admitted with severe abdominal pain. Which assessment finding should the nurse report to the healthcare provider immediately?
- A. Bowel sounds active in all quadrants.
- B. Blood pressure of 110/70 mm Hg.
- C. Rigid, board-like abdomen.
- D. Heart rate of 90 beats per minute.
Correct Answer: C
Rationale: The correct answer is C: Rigid, board-like abdomen. This finding suggests peritonitis, a serious complication of peptic ulcer disease, requiring immediate medical intervention. A: Active bowel sounds are expected. B: Blood pressure is within normal range. D: Heart rate is slightly elevated but not a critical finding. In summary, a rigid abdomen indicates peritonitis and requires urgent attention compared to the other choices.
A patient with bipolar disorder is prescribed valproic acid. What is an important side effect for the nurse to monitor?
- A. Hypertension
- B. Liver toxicity
- C. Hyperglycemia
- D. Bradycardia
Correct Answer: B
Rationale: Correct Answer: B (Liver toxicity)
Rationale:
1. Valproic acid is known to cause liver toxicity.
2. The nurse should monitor liver function tests regularly.
3. Signs of liver toxicity include jaundice, abdominal pain, and nausea.
4. Prompt detection is crucial to prevent serious complications.
Summary:
A: Hypertension - Not a common side effect of valproic acid.
C: Hyperglycemia - More commonly associated with other medications like antipsychotics.
D: Bradycardia - Not a typical side effect of valproic acid.
The healthcare provider formulates a nursing diagnosis of 'High risk for ineffective airway clearance' for a client with myasthenia gravis. What is the most likely cause for this nursing diagnosis?
- A. Pain during coughing.
- B. Diminished cough effort.
- C. Thick, dry secretions.
- D. Excessive inflammation.
Correct Answer: B
Rationale: The correct answer is B: Diminished cough effort. In myasthenia gravis, muscle weakness can affect the muscles involved in coughing, leading to diminished cough effort. This can result in ineffective airway clearance, putting the client at high risk for respiratory complications. Pain during coughing (choice A) may occur but is not the primary cause of ineffective airway clearance in myasthenia gravis. Thick, dry secretions (choice C) and excessive inflammation (choice D) may contribute to airway clearance issues but are not as directly related to the underlying muscle weakness seen in myasthenia gravis.
For a patient with asthma, what is the primary purpose of prescribing montelukast?
- A. Relieve acute bronchospasm
- B. Prevent asthma attacks
- C. Thin respiratory secretions
- D. Suppress cough
Correct Answer: B
Rationale: The primary purpose of prescribing montelukast for a patient with asthma is to prevent asthma attacks. Montelukast is a leukotriene receptor antagonist that helps to reduce inflammation in the airways, thereby preventing asthma symptoms and attacks. It is not used to relieve acute bronchospasm (Choice A), as it is not a fast-acting rescue medication like a bronchodilator. Montelukast also does not thin respiratory secretions (Choice C) or suppress cough (Choice D) as its main mechanism of action is to prevent and control asthma symptoms by inhibiting leukotrienes.
A patient with depression is prescribed fluoxetine. What is an important side effect for the nurse to monitor?
- A. Weight gain
- B. Bradycardia
- C. Dry mouth
- D. Suicidal thoughts
Correct Answer: D
Rationale: The correct answer is D: Suicidal thoughts. When a patient with depression is prescribed fluoxetine, there is a risk of increased suicidal thoughts, especially in the initial weeks of treatment. This is important for the nurse to monitor because it can lead to serious consequences. Weight gain (A) is a common side effect of fluoxetine but not as critical to monitor as suicidal thoughts. Bradycardia (B) and dry mouth (C) are not common side effects of fluoxetine and are less relevant to monitor in this scenario. Monitoring for suicidal thoughts is crucial for patient safety.