Nokea
A client with heart failure is receiving digoxin (Lanoxin) and furosemide (Lasix). Which assessment finding requires immediate intervention?
- A. Heart rate of 60 beats per minute
- B. Apical pulse of 58 beats per minute
- C. Presence of a new murmur
- D. Blood pressure of 100/60 mmHg
Correct Answer: C
Rationale: The correct answer is C. The presence of a new murmur in a client with heart failure receiving digoxin and furosemide is concerning as it may indicate valvular problems or other complications that require immediate intervention. A heart rate of 60 beats per minute and an apical pulse of 58 beats per minute are within normal limits for a client with heart failure on these medications. A blood pressure of 100/60 mmHg, while slightly low, may be expected due to the diuretic effect of furosemide and may not require immediate intervention unless the client is symptomatic.
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An older female client tells the nurse that her muscles have gradually been getting weaker over time. What is the best initial response by the nurse?
- A. Explain that this is an expected occurrence with aging.
- B. Observe the lower extremities for signs of muscle atrophy.
- C. Review the medical record for recent diagnostic test results.
- D. Ask the client to describe the changes that have occurred.
Correct Answer: D
Rationale: The best initial response by the nurse should be to ask the client to describe the changes that have occurred. This open-ended question allows the nurse to gather valuable information directly from the client, aiding in assessing the situation accurately and formulating an appropriate care plan. Choice A is incorrect as assuming muscle weakness is an expected occurrence with aging without further assessment may overlook potential underlying issues. Choice B is premature as it jumps straight to physical examination without first gathering subjective data. Choice C is unnecessary at this point as reviewing diagnostic test results should come after initial assessment and data collection from the client.
Following an open reduction of the tibia, the nurse notes bleeding on the client's cast. Which action should the nurse implement?
- A. Outline the area with ink and check it every 15 minutes to see if the area has increased
- B. Notify the healthcare provider immediately
- C. Apply a new cast to stop the bleeding
- D. Elevate the limb to reduce blood flow
Correct Answer: A
Rationale: After an open reduction of the tibia, bleeding on the cast can be a concern. Outlining the area with ink and monitoring it every 15 minutes is the appropriate action to assess if the bleeding is worsening, indicating the need for further intervention. This action allows for close observation without disturbing the cast.
Choice B is incorrect because while notifying the healthcare provider is important, immediate action is not always necessary if the bleeding is not severe. Choice C is incorrect because applying a new cast is not the standard intervention for bleeding on a cast. Choice D is incorrect because elevating the limb may not address the underlying cause of bleeding and may not be the most appropriate action at this time.
A nurse is teaching a client with type 2 diabetes about the importance of foot care. Which statement by the client indicates a need for further teaching?
- A. I should check my feet every day for cuts or blisters.
- B. I need to moisturize my feet daily, especially between my toes.
- C. I should wear comfortable shoes that fit well.
- D. I should avoid walking barefoot, even indoors.
Correct Answer: B
Rationale: The correct answer is B. Moisturizing between the toes can create a moist environment that fosters fungal infections. Checking the feet daily for cuts or blisters (choice A) is correct in diabetes management to prevent complications. Wearing comfortable shoes that fit well (choice C) and avoiding walking barefoot (choice D) are also essential in preventing foot ulcers and injuries in diabetic patients.
Which nursing intervention is most important when caring for a client with myasthenia gravis?
- A. Encourage the client to rest frequently.
- B. Administer medication 30 minutes before meals.
- C. Maintain a patent airway.
- D. Monitor for signs of respiratory infection.
Correct Answer: C
Rationale: Maintaining a patent airway is crucial for clients with myasthenia gravis because muscle weakness can affect the muscles responsible for breathing, potentially leading to respiratory compromise. Encouraging rest, administering medication, and monitoring for respiratory infections are important aspects of care but do not take precedence over ensuring a patent airway for adequate oxygenation.
A client with chronic kidney disease (CKD) is admitted with hyperkalemia. Which intervention should the nurse implement first?
- A. Administer intravenous calcium gluconate.
- B. Administer intravenous insulin and glucose.
- C. Administer intravenous sodium bicarbonate.
- D. Administer a loop diuretic as prescribed.
Correct Answer: B
Rationale: The correct answer is to administer intravenous insulin and glucose first. This intervention helps drive potassium back into the cells, lowering serum levels effectively. Administering intravenous calcium gluconate (choice A) is used to stabilize cardiac membranes in severe hyperkalemia but does not address the underlying cause. Administering intravenous sodium bicarbonate (choice C) is used in metabolic acidosis, not hyperkalemia. Administering a loop diuretic (choice D) can help eliminate potassium but is not the first-line treatment for hyperkalemia in CKD.