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A healthcare professional is preparing to administer digoxin (Lanoxin), 0.125 mg orally, to a client with heart failure. Which vital sign is most important for the healthcare professional to check before administering the medication?
- A. Heart rate
- B. Temperature
- C. Respirations
- D. Blood pressure
Correct Answer: A
Rationale: Before administering digoxin, it is essential to assess the client's heart rate as this medication directly affects cardiac function. Monitoring the heart rate helps identify if it is within the acceptable range for administering digoxin. A pulse rate below 60 beats per minute warrants withholding the medication to prevent potential adverse effects like bradycardia or cardiac arrhythmias.
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A nurse is monitoring a client receiving lithium carbonate for bipolar disorder. Which finding should the nurse report immediately to the healthcare provider?
- A. Increased thirst
- B. Fine hand tremors
- C. Frequent urination
- D. Persistent vomiting
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client with a gastric ulcer has a prescription for sucralfate (Carafate), 1 g by mouth four times daily. The nurse schedules the medication for which times?
- A. With meals and at bedtime
- B. Every 6 hours around the clock
- C. One hour after meals and at bedtime
- D. One hour before meals and at bedtime
Correct Answer: D
Rationale: Sucralfate is a gastric protectant that forms a protective coating over the ulcer. Administering sucralfate 1 hour before meals and at bedtime is important to create a barrier that protects the ulcer from gastric acid and mechanical irritation. This timing allows sucralfate to effectively coat the ulcer site and provide the desired therapeutic effect, enhancing its efficacy in promoting ulcer healing and symptom relief.
A client with hypertension is prescribed lisinopril (Zestril). Which instruction should the nurse include in the teaching plan?
- A. Avoid foods high in potassium.
- B. Avoid taking the medication with grapefruit juice.
- C. Monitor blood pressure regularly.
- D. Report any swelling of the lips or face.
Correct Answer: D
Rationale: The correct instruction for the nurse to include in the teaching plan is to 'Report any swelling of the lips or face.' Lisinopril (Zestril) can cause angioedema, which is swelling of the lips or face. This is a serious side effect that should be reported immediately. Clients do not need to avoid potassium-rich foods unless instructed by their healthcare provider, should avoid taking the medication with grapefruit juice, and should monitor their blood pressure regularly, not just weekly.
While assisting in caring for a pregnant client receiving intravenous magnesium sulfate for preeclampsia management, a nurse notes the client's absent deep tendon reflexes. What determination should the nurse make based on this data?
- A. The magnesium sulfate is effective.
- B. The infusion rate needs to be increased.
- C. The client is experiencing cerebral edema.
- D. The client is experiencing magnesium toxicity.
Correct Answer: D
Rationale: When a pregnant client receiving intravenous magnesium sulfate for preeclampsia management exhibits absent deep tendon reflexes, this indicates magnesium toxicity. Magnesium toxicity can occur as a complication of magnesium sulfate therapy, leading to suppressed reflexes. It is crucial for the nurse to recognize this sign promptly and report it to prevent further complications or harm to the client.
A client is taking propranolol (Inderal LA). Which data collection finding would indicate a potential serious complication associated with propranolol?
- A. The development of complaints of insomnia
- B. The development of audible expiratory wheezes
- C. A baseline blood pressure of 150/80 mm Hg followed by a blood pressure of 138/72 mm Hg after two doses of the medication
- D. A baseline resting heart rate of 88 beats/min followed by a resting heart rate of 72 beats/min after two doses of the medication
Correct Answer: B
Rationale: The development of audible expiratory wheezes may indicate a serious adverse reaction, bronchospasm, associated with propranolol. Beta-blockers can trigger bronchospasm, especially in clients with chronic obstructive pulmonary disease or asthma. This complication can lead to significant respiratory distress and should be addressed promptly to prevent further complications.