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 client with diabetes mellitus is prescribed prednisone for an acute exacerbation of asthma. Which of the following should the nurse include in the client's teaching plan?
- A. Increase the dose of insulin while taking prednisone.
- B. Take the prednisone with food.
- C. Monitor blood glucose levels closely.
- D. Do not discontinue prednisone abruptly.
Correct Answer: C
Rationale: The correct answer is to monitor blood glucose levels closely. Prednisone can elevate blood glucose levels, necessitating close monitoring. Adjusting the insulin dose may be necessary, but this should be managed by a healthcare provider. Prednisone should be taken with food to reduce gastrointestinal discomfort and should not be stopped suddenly to prevent adverse effects.
A client is being cared for by a nurse due to severe back pain, and codeine sulfate has been prescribed. Which of the following should the nurse include in the plan of care while the client is taking this medication?
- A. Restrict fluid intake.
- B. Monitor bowel activity.
- C. Monitor for hypertension.
- D. Monitor peripheral pulses.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A home health care nurse is visiting a client with elevated triglyceride levels and a serum cholesterol level of 398 mg/dL. The client is taking cholestyramine (Questran). Which of the following statements, if made by the client, indicates the need for further education?
- A. Constipation and bloating might be a problem.
- B. I'll continue to watch my diet and reduce my fats.
- C. Walking a mile each day will help the whole process.
- D. I'll continue my nicotinic acid from the health food store.
Correct Answer: D
Rationale: Nicotinic acid, even an over-the-counter form, should be avoided because it may lead to liver abnormalities. All lipid-lowering medications also can cause liver abnormalities, so a combination of nicotinic acid and cholestyramine resin is to be avoided. Constipation and bloating are the two most common side effects. Walking and the reduction of fats in the diet are therapeutic measures to reduce cholesterol and triglyceride levels.
Rifabutin (Mycobutin) is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. The nurse monitors for which side effects of the medication? Select one that doesn't apply.
- A. Signs of hepatitis
- B. Flu-like syndrome
- C. Low neutrophil count
- D. Vitamin B6 deficiency
Correct Answer: D
Rationale: Rifabutin is known to cause side effects such as hepatitis, flu-like syndrome, low neutrophil count, and ocular pain or blurred vision. Vitamin B6 deficiency is not associated with rifabutin but is a side effect of isoniazid (INH). Therefore, the nurse should not monitor for Vitamin B6 deficiency when administering rifabutin.
A client is diagnosed with pulmonary embolism and is to be treated with streptokinase (Streptase). A nurse would report which priority data collection finding to the registered nurse before initiating this therapy?
- A. Adventitious breath sounds
- B. Temperature of 99.4°F orally
- C. Blood pressure of 198/110 mm Hg
- D. Respiratory rate of 28 breaths/min
Correct Answer: C
Rationale: The correct answer is C. Streptokinase therapy is contraindicated in severe uncontrolled hypertension due to the risk of cerebral hemorrhage. A blood pressure of 198/110 mm Hg indicates severe hypertension, which needs to be addressed before initiating streptokinase to prevent potential complications.
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