Nokea
A loading dose of digoxin (Lanoxin) is given to a client newly diagnosed with atrial fibrillation. The nurse begins instruction in the medication and the importance of monitoring his heart rate. An expected outcome of the education program will be:
- A. A return demonstration of palpating the radial pulse.
- B. A return demonstration of how to take the medication.
- C. Verbalization of why the client has atrial fibrillation.
- D. Verbalization of the need for the medication.
Correct Answer: A
Rationale: Teaching the client to monitor their radial pulse ensures they can detect irregularities or bradycardia, a critical aspect of managing digoxin therapy.
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The nurse fails to recognize that a client's vital signs have deteriorated over the past 4 hours after surgery. Later, the client requires emergency surgery. Which legal consequence does the nurse potentially face because of a failure to act?
- A. Tort
- B. Statutory law
- C. Common law
- D. Misdemeanor
Correct Answer: A
Rationale: The nurse's inaction is consistent with a tort offense because a tort is a wrongful act intentionally or unintentionally committed against a person or the person's property. Option 2 describes laws that are enacted by state, federal, or local governments. Option 3 describes case law that has evolved over time via precedents. Option 4 is an offense under criminal law.
A client has polycystic kidney disease. The client asks the nurse, 'How did I get these fluid-filled bubbles on my kidneys? I have not had any X-ray type tests.' How should the nurse respond to help the client understand risk factors for this disease process?
- A. Second-hand smoke puts you at greater risk for developing cysts.'
- B. Exposure to dyes used to color fruits and vegetables increases the risk of polycystic kidney disease.'
- C. There is a higher incidence of polycystic kidney disease among blood relatives.'
- D. Drinking alcohol daily allows the kidneys to develop cysts.'
Correct Answer: C
Rationale: Polycystic kidney disease is primarily genetic, with a higher incidence among blood relatives due to autosomal dominant or recessive inheritance patterns.
Which sign/symptom is an indication that the client experiencing postoperative blood loss is anemic?
- A. Fatigue
- B. Dyspnea
- C. Bradycardia
- D. Muscle cramps
Correct Answer: A
Rationale: The client with anemia is likely to report fatigue caused by deficient hemoglobin leading to a decreased oxygen-carrying capacity of the blood and ability to meet tissue oxygen demands. The respiratory rate can increase to improve oxygenation; some shortness of breath can occur but dyspnea related to anemia is uncommon. The client is more likely to have tachycardia than bradycardia, because the heart beats faster to deliver the same amount of oxygen to tissues in compensation for less oxygen in the blood. Muscle cramps are an unrelated finding.
The nurse performs an assessment on a client with cancer and notes that the client is receiving pain medication via this type of catheter. (Refer to the figure.) What should the nurse document that the client has?
- A. Epidural catheter
- B. Hickman catheter
- C. Central venous catheter (CVC)
- D. Patient-controlled analgesia (PCA) pump
Correct Answer: A
Rationale: An epidural catheter is placed in the epidural space. The epidural space lies between the dura mater and the vertebral column. When an opioid is injected into the epidural space, it binds to opiate receptors located on the dorsal horn of the spinal cord and blocks the transmission of pain impulses to the cerebral cortex of the brain. Because the opioid does not cross the blood-brain barrier, pain relief results from drug levels in the spinal cord rather than in the plasma, with little central or systemic distribution of the medication. A Hickman catheter is a vascular access device that is surgically inserted, tunneled through the subcutaneous tissue, and is used to manage long-term intravenous therapy. A CVC is inserted into a large vein (typically the internal or external jugular or the superior vena cava) that leads to the right atrium of the heart. A PCA pump is the device that allows the client to self-administer pain medication.
A client has been diagnosed with right-sided heart failure. The nurse should assess the client further for:
- A. Intermittent claudication.
- B. Dyspnea.
- C. Dependent edema.
- D. Crackles.
Correct Answer: C
Rationale: Dependent edema is a key sign of right-sided heart failure, as the heart fails to pump blood effectively, causing fluid backup in the extremities.