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.
You may also like to solve these questions
The nurse needs to add a medication to a liter of 5% Dextrose in Water (D5W) that is already infusing into a client. At what location should the nurse inject the medication?
- A. Medication port
- B. IV drip chamber
- C. Y-site connector
- D. At the hub of the IV catheter
Correct Answer: A
Rationale: The correct answer is the medication port. When adding medication to an already infusing IV solution, it should be done through the medication port to ensure direct delivery into the bloodstream without interrupting the primary IV line. Injecting the medication into the IV drip chamber, Y-site connector, or at the hub of the IV catheter can lead to dilution, inaccurate dosing, or potential blockages in the IV line, which can compromise the effectiveness of the medication and patient safety.
When a client with a history of atrial fibrillation is admitted with a new onset of confusion, which diagnostic test should the nurse anticipate preparing the client for first?
- A. Electrocardiogram (ECG)
- B. Chest X-ray
- C. Arterial blood gases (ABGs)
- D. Echocardiogram
Correct Answer: A
Rationale: The correct answer is an Electrocardiogram (ECG). When a client with a history of atrial fibrillation presents with new-onset confusion, an ECG is crucial to assess for cardiac ischemia, which could be a potential cause of the confusion. A chest X-ray (Choice B) is not typically the first-line diagnostic test for evaluating confusion in a client with atrial fibrillation. Arterial blood gases (ABGs) (Choice C) are more useful in assessing oxygenation and acid-base balance rather than the cause of confusion in this scenario. While an echocardiogram (Choice D) provides valuable information about cardiac structure and function, it is usually not the initial diagnostic test needed in the evaluation of acute confusion in a client with atrial fibrillation.
The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which intervention should the nurse implement first?
- A. Elevate the head of the bed.
- B. Administer oxygen therapy as prescribed.
- C. Assess the client's oxygen saturation.
- D. Obtain an arterial blood gas (ABG) sample.
Correct Answer: C
Rationale: Assessing the client's oxygen saturation is the first priority in managing a client with COPD receiving supplemental oxygen to ensure adequate oxygenation. Monitoring oxygen saturation levels helps in determining the effectiveness of the oxygen therapy and if adjustments are needed. Elevating the head of the bed can help with breathing but is not the first priority. Administering oxygen therapy as prescribed is important, but assessing the current oxygen saturation comes before administering more oxygen. Obtaining an arterial blood gas (ABG) sample may provide valuable information, but it is not the initial intervention needed in this situation.
The nurse is caring for a client with end-stage renal disease (ESRD) who is scheduled for hemodialysis. Which clinical finding is most concerning?
- A. Blood pressure of 110/70 mmHg
- B. Heart rate of 110 beats per minute
- C. Fever of 100.4°F
- D. Respiratory rate of 24 breaths per minute
Correct Answer: C
Rationale: The correct answer is C. A fever of 100.4°F is most concerning in a client with ESRD scheduled for hemodialysis because it may indicate an underlying infection that requires immediate attention. Elevated body temperature can be a sign of systemic infection, which can quickly worsen in individuals with compromised renal function. Monitoring for infection is crucial in ESRD patients to prevent complications. Choices A, B, and D are not as immediately concerning in this context. While variations in blood pressure, heart rate, and respiratory rate should be monitored, they are not as indicative of a potentially severe issue as an unexplained fever in this scenario.
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.