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A client with heart failure is receiving intravenous furosemide (Lasix). Which assessment finding indicates that the medication is having the desired effect?
- A. Decreased peripheral edema.
- B. Elevated blood pressure.
- C. Increased heart rate.
- D. Decreased urine output.
Correct Answer: A
Rationale: The correct answer is A: Decreased peripheral edema. Furosemide is a diuretic that helps to remove excess fluid from the body, which can reduce peripheral edema in patients with heart failure. This indicates that the medication is effectively reducing fluid overload in the body. Elevated blood pressure (choice B) would not be an expected outcome of furosemide use. Increased heart rate (choice C) is not a direct effect of furosemide and can indicate worsening heart failure. Decreased urine output (choice D) would be an adverse effect of furosemide and would indicate the medication is not working as intended.
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While assessing a client with diabetes mellitus, the nurse observes an absence of hair growth on the client's legs. What additional assessment provides further data to support this finding?
- A. Palpate for the presence of femoral pulses bilaterally.
- B. Assess for the presence of a positive Homan's sign.
- C. Observe the appearance of the skin on the client's legs.
- D. Watch the client's posture and balance during ambulation.
Correct Answer: C
Rationale: The correct answer is C: Observe the appearance of the skin on the client's legs. In clients with diabetes mellitus, poor circulation can lead to decreased hair growth on the legs. By observing the skin appearance, the nurse can look for signs of poor circulation such as dry skin, thinning of the skin, or discoloration. This assessment provides further data to support the finding of absent hair growth.
Choices A, B, and D are incorrect because they do not directly relate to the assessment of absent hair growth in clients with diabetes mellitus. Palpating for femoral pulses assesses circulation but does not specifically address the absence of hair growth. Assessing for Homan's sign evaluates for deep vein thrombosis, which is not directly related to hair growth. Watching posture and balance during ambulation assesses mobility and stability but does not provide information on hair growth or circulation in the legs.
The nurse formulates a nursing diagnosis of 'High risk for ineffective airway clearance' for a client with myasthenia gravis. What is the most likely etiology for this nursing diagnosis?
- A. Pain when 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 respiratory muscles, leading to ineffective coughing and clearance of airways. Diminished cough effort can result in ineffective airway clearance, putting the client at high risk for respiratory complications.
A: Pain when coughing is not the primary etiology for ineffective airway clearance in myasthenia gravis.
C: Thick, dry secretions may contribute to airway clearance issues but are not the most likely etiology compared to diminished cough effort.
D: Excessive inflammation is not typically associated with ineffective airway clearance in myasthenia gravis.
What is the primary advantage of prescribing rivaroxaban over warfarin for a patient with a history of deep vein thrombosis (DVT)?
- A. No need for regular INR monitoring
- B. Lower risk of bleeding
- C. Fewer dietary restrictions
- D. Longer half-life
Correct Answer: A
Rationale: The primary advantage of prescribing rivaroxaban over warfarin for a patient with a history of DVT is the absence of regular INR monitoring required with rivaroxaban. This is because rivaroxaban is a direct oral anticoagulant with more predictable pharmacokinetics, eliminating the need for monitoring. Regular INR monitoring is necessary with warfarin to ensure the drug is within the therapeutic range, which can be burdensome for patients and healthcare providers. The other choices are incorrect as they do not directly address the primary advantage of rivaroxaban over warfarin for this specific patient population.
Following a CVA, the nurse assesses that a client has developed dysphagia, hypoactive bowel sounds, and a firm, distended abdomen. Which prescription for the client should the nurse question?
- A. Continuous tube feeding at 65 ml/hr via gastrostomy.
- B. Total parenteral nutrition to be infused at 125 ml/hour.
- C. Nasogastric tube connected to low intermittent suction.
- D. Metoclopramide (Reglan) intermittent piggyback.
Correct Answer: A
Rationale: The correct answer is A: Continuous tube feeding at 65 ml/hr via gastrostomy. After a CVA, dysphagia, hypoactive bowel sounds, and a firm, distended abdomen indicate a risk for aspiration and bowel obstruction. Continuous tube feeding may worsen these issues. Option B provides nutrition intravenously, bypassing the gastrointestinal tract. Option C helps decompress the stomach. Option D is a medication to help with GI motility. Therefore, the nurse should question option A due to the risk of complications post-CVA.
A patient with type 1 diabetes is prescribed insulin glargine. What is the primary characteristic of this insulin?
- A. Rapid-acting
- B. Intermediate-acting
- C. Long-acting
- D. Short-acting
Correct Answer: C
Rationale: Insulin glargine is a long-acting insulin due to its slow and consistent release, providing basal insulin coverage for about 24 hours. This steady release mimics the body's natural basal insulin secretion pattern. Rapid-acting insulins (A) work quickly to control postprandial glucose levels. Intermediate-acting insulins (B) have a slower onset and last for a moderate duration. Short-acting insulins (D) act quickly but have a shorter duration of action compared to long-acting insulins.