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A client with heart failure is receiving digoxin (Lanoxin). Which finding indicates that the medication is effective?
- A. Increased heart rate.
- B. Decreased pedal edema.
- C. Elevated blood pressure.
- D. Improved urine output.
Correct Answer: B
Rationale: The correct answer is B: Decreased pedal edema. Digoxin is a medication commonly used to treat heart failure by improving the heart's ability to pump effectively. As the medication helps to reduce fluid buildup in the body, a decrease in pedal edema (swelling in the feet and ankles) indicates that digoxin is effectively managing the client's heart failure. Increased heart rate (A) may indicate digoxin toxicity, elevated blood pressure (C) is not a typical indicator of digoxin effectiveness, and improved urine output (D) may be a result of diuretic therapy rather than specifically digoxin efficacy in heart failure management.
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A client with a history of myocardial infarction (MI) is prescribed atorvastatin (Lipitor). Which outcome indicates that the medication is effective?
- A. Increased blood pressure.
- B. Lowered cholesterol levels.
- C. Decreased heart rate.
- D. Improved liver function.
Correct Answer: B
Rationale: The correct answer is B: Lowered cholesterol levels. Atorvastatin is a statin medication used to lower cholesterol levels, reducing the risk of further cardiovascular events in patients with a history of MI. Lowering cholesterol helps prevent plaque buildup in arteries, reducing the likelihood of another MI. Increased blood pressure (A) and decreased heart rate (C) are not direct indicators of atorvastatin's effectiveness. Improved liver function (D) may be a consideration due to potential side effects, but the primary goal of atorvastatin is to lower cholesterol levels to prevent cardiovascular events.
The nurse is caring for a client who is receiving chemotherapy. Which laboratory result indicates that the client is at risk for infection?
- A. Hemoglobin level of 12 g/dL.
- B. Platelet count of 150,000/mm3.
- C. White blood cell count of 2,000/mm3.
- D. Serum creatinine level of 1.0 mg/dL.
Correct Answer: C
Rationale: The correct answer is C: White blood cell count of 2,000/mm3. A low white blood cell count indicates leukopenia, which increases the risk of infection in clients receiving chemotherapy. Hemoglobin level (choice A) and platelet count (choice B) are not directly related to infection risk. Serum creatinine level (choice D) is related to kidney function, not infection risk. In summary, a low white blood cell count is the most critical indicator for infection risk in clients undergoing chemotherapy.
A client who participates in a health maintenance organization (HMO) needs a bone marrow transplant for the treatment of breast cancer. The client tells the nurse that she is concerned that her HMO may deny her claim. What action by the nurse best addresses the client's need at this time?
- A. Have the client's healthcare provider write a letter to the HMO explaining the need for the transplant.
- B. Help the client place a call to the HMO to seek information about limitations of coverage.
- C. Encourage the client to contact a lawyer to file a lawsuit against the HMO if necessary.
- D. Have the social worker contact the state board of insurance to register a complaint against the HMO.
Correct Answer: B
Rationale: The correct answer is B: Help the client place a call to the HMO to seek information about limitations of coverage. This is the best action because it directly addresses the client's concern by clarifying the coverage for the bone marrow transplant. By contacting the HMO, the client can get accurate information on whether the transplant is covered and what steps need to be taken for approval. This empowers the client to make informed decisions regarding their healthcare.
Choice A is incorrect because having the healthcare provider write a letter may not directly address the client's concerns about coverage. Choice C is incorrect as contacting a lawyer should be a last resort after exploring other options. Choice D is incorrect as involving the state board of insurance is not necessary at this stage and may escalate the situation unnecessarily.
The nurse is caring for a client with hyperthyroidism. Which intervention should the nurse implement to manage the client's condition?
- A. Provide a high-calorie diet.
- B. Encourage frequent rest periods.
- C. Restrict fluid intake.
- D. Administer a stool softener.
Correct Answer: B
Rationale: The correct answer is B: Encourage frequent rest periods. For a client with hyperthyroidism, rest is crucial to conserve energy and support the body's recovery. Hyperthyroidism is characterized by increased metabolic rate, leading to fatigue and weakness. Rest periods help reduce metabolic demands and prevent exhaustion. A high-calorie diet (choice A) may be necessary to support increased metabolism but is not the priority. Restricting fluid intake (choice C) can lead to dehydration, which should be avoided in hyperthyroidism. Administering a stool softener (choice D) is unrelated to managing hyperthyroidism.
The healthcare provider is caring for a client with Guillain-Barr© syndrome. Which assessment finding requires the healthcare provider's immediate action?
- A. Loss of deep tendon reflexes.
- B. Ascending weakness.
- C. New onset of confusion.
- D. Decreased vital capacity.
Correct Answer: D
Rationale: The correct answer is D: Decreased vital capacity. This finding indicates respiratory muscle weakness, which can lead to respiratory failure in Guillain-Barr© syndrome. Immediate action is needed to prevent respiratory compromise. Choice A is a common finding in Guillain-Barr© and does not require immediate action. Choice B is characteristic of Guillain-Barr© and should be monitored but not the most urgent. Choice C could indicate other issues but is not as critical as respiratory compromise.