Nokea
A five-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery?
- A. Decreased appetite
- B. A low-grade fever
- C. Chest congestion
- D. Constant swallowing
Correct Answer: D
Rationale: Constant swallowing post-tonsillectomy suggests bleeding, as the child may be swallowing blood from the surgical site, a serious complication requiring immediate attention. Decreased appetite and low-grade fever are expected, and chest congestion is unrelated.
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The client is prescribed digoxin (Lanoxin) for heart failure. Which instruction should the nurse include in the teaching plan?
- A. Take the medication with meals to prevent nausea.'
- B. Report a pulse below 60 beats per minute.'
- C. Increase potassium-rich foods in your diet.'
- D. Take an extra dose if you miss one.'
Correct Answer: B
Rationale: Digoxin toxicity is increased with bradycardia, so a pulse below 60 beats per minute should be reported. It can be taken with or without food, potassium monitoring is important but not increasing, and extra doses are dangerous.
Prior to administering digoxin to a client with congestive heart failure, the nurse needs to assess:
- A. Respiratory rate for 1 minute
- B. Radial pulse for 1 minute
- C. Radial pulse for 2 minutes
- D. Apical pulse for 1 minute
Correct Answer: D
Rationale: Apical pulse should be measured for 1-minute prior to digoxin administration. Digoxin decreases the heart rate. Digoxin should be withheld if apical rates are <60 bpm or >120 bpm.
The physician has ordered a low-residue diet for a client with Crohn's disease. Which food is not permitted in a low-residue diet?
- A. Mashed potatoes
- B. Smooth peanut butter
- C. Fried fish
- D. Rice
Correct Answer: C
Rationale: A low-residue diet minimizes fiber and irritating foods; fried fish is high in fat and can irritate the gut, making it unsuitable for Crohn's disease.
The nurse is teaching a client with a history of atrial fibrillation about medication adherence. The nurse should tell the client to:
- A. Take anticoagulants as prescribed
- B. Skip doses if feeling better
- C. Increase caffeine intake
- D. Avoid hydration
Correct Answer: A
Rationale: Anticoagulants reduce stroke risk in atrial fibrillation, so adherence is critical.
A client requires log rolling after back surgery. Correctly provide the sequence of steps the nurse should follow when performing the procedure.
- A. Obtain assistance; three nurses are preferable.
- B. Maintain client's position in alignment with pillows.
- C. Position two nurses on the side the client will be turned to and the third nurse on the opposite side of the bed.
- D. Designate the person at the head of the bed to be in charge of coordinating the move.
- E. Place a pillow between the client's knees.
- F. Move the client in one coordinated movement when the nurse at the head of the bed signals to move the client.
- G. Instruct the client to place the arms across the chest.
Correct Answer: A, C, D, G, E, B, F
Rationale: Log rolling sequence: Obtain assistance (A), position nurses (C), designate leader (D), instruct arm placement (G), place pillow (E), align with pillows (B), move coordinately (F).