A male client has been hospitalized with congestive heart failure. Medical management of heart failure focuses on improving myocardial contractility. This can be achieved by administering:
- A. Digoxin (Lanoxin) 0.25 mg po every day
- B. Furosemide (Lasix) 40 mg po every morning
- C. O2 2 L/min via nasal cannula
- D. Nitroglycerin (Nitrol) 1 inch topically every 4 hours
Correct Answer: A
Rationale: Digoxin enhances myocardial contractility, improving cardiac output in heart failure.
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An 80-year-old widow is living with her son and daughter-in-law. The home health nurse has been making weekly visits to draw blood for a prothrombin time test. The client is taking 5 mg of coumadin per day. She appears more debilitated, and bruises are noted on her face. Elder abuse is suspected. Which of the following are signs of persons who are at risk for abusing an elderly person?
- A. A family member who is having marital problems and is regularly abusing alcohol
- B. A person with adequate communication and coping skills who is employed by the family
- C. A friend of the family who wants to help but is minimally competent
- D. A lifelong friend of the client who is often confused
Correct Answer: A
Rationale: This answer is correct. Two risk factors are identified in this answer. This answer is incorrect. Persons at risk tend to lack communication skills and effective coping patterns. This answer is incorrect. Persons at risk are usually family members or those reluctant to provide care. This answer is incorrect. This individual has a vested interest in providing care.
A client is pleased about being pregnant, yet states, 'It is really not the best time, but I guess it will be OK.' The nurse's assessment of this response is:
- A. Initial maternal-infant bonding may be poor.
- B. Client may have a poor relationship with her husband.
- C. This response is normal in the first trimester.
- D. This response is abnormal, to be re-evaluated at the next visit.
Correct Answer: C
Rationale: Ambivalence is normal during the first trimester. Reva Rubin addresses the issue of 'not now' in the first trimester. The statement still leaves room for exploration. There are no data to support this. This statement by the mother still leaves room for exploration. Ambivalence is normal during the first trimester. Reva Rubin addresses the issue of 'not now.' This fact should be shared with the mother during further exploration of the comment. It is not abnormal. If it were, another month would also be too long to wait.
An elderly client refuses to take her daily medication for hypertension. Which action should the nurse take at this time?
- A. Administer the medication by injection
- B. Obtain help administering the medication
- C. Skip the dose of medication and attempt to give it later
- D. Explore the reason for the client’s refusal to take the medication
Correct Answer: D
Rationale: Exploring the reason for the client’s refusal respects autonomy and may reveal misunderstandings, fears, or side effects that can be addressed. Administering by injection or with help violates autonomy, and skipping the dose delays treatment without addressing the issue.
The obstetric client's fetal heart rate is 80-90 during the contractions. The first action the nurse should take is:
- A. Reposition the monitor
- B. Turn the client to her left side
- C. Ask the client to ambulate
- D. Prepare the client for delivery
Correct Answer: B
Rationale: A fetal heart rate of 80-90 during contractions indicates bradycardia possibly from cord compression or uteroplacental insufficiency. Turning the client to her left side improves placental perfusion and is the first action.
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.
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