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A nurse is assessing a client who has heart failure and is receiving digoxin. Which of the following findings should the nurse identify as an indication of digoxin toxicity?
- A. Bradycardia.
- B. Tachycardia.
- C. Nausea.
- D. Blurred vision.
Correct Answer: D
Rationale: Corrected Rationale: Blurred vision is a classic sign of digoxin toxicity, indicating a potential overdose. It is crucial to recognize this symptom promptly and report it to the healthcare provider for immediate intervention. Bradycardia and nausea are common side effects of digoxin but not specific indicators of toxicity. Tachycardia is unlikely in digoxin toxicity since it usually causes a decrease in heart rate.
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A nurse is providing discharge teaching to a client who has a new prescription for digoxin. Which of the following instructions should the nurse include?
- A. Take this medication at bedtime.
- B. Take your pulse before taking this medication.
- C. Avoid eating foods high in potassium.
- D. Take this medication with an antacid.
Correct Answer: B
Rationale: The correct instruction for the nurse to include is to advise the client to take their pulse before taking digoxin. This is important to monitor for bradycardia, a potential side effect of the medication. Option A is incorrect because digoxin is usually taken in the morning. Option C is unrelated to digoxin therapy, as high potassium foods are usually restricted in clients taking potassium-sparing diuretics. Option D is incorrect because digoxin should not be taken with antacids as they can affect its absorption.
A client is receiving discharge teaching about a new prescription for ferrous sulfate. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication with milk.
- B. I should expect my stools to turn black.
- C. I should avoid eating oranges while taking this medication.
- D. I will take this medication on an empty stomach.
Correct Answer: B
Rationale: The correct answer is B. When taking ferrous sulfate, clients should expect their stools to turn black, which is a normal side effect due to the iron content. Choice A is incorrect because ferrous sulfate should not be taken with milk as it can decrease its absorption. Choice C is incorrect because vitamin C-rich foods like oranges can actually enhance the absorption of iron. Choice D is incorrect because ferrous sulfate is usually recommended to be taken on an empty stomach for better absorption.
A nurse is assessing a client who is postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?
- A. Heart rate 110/min.
- B. Temperature of 37.4°C (99.3°F).
- C. Respiratory rate of 18/min.
- D. Urine output of 20 mL/hr.
Correct Answer: D
Rationale: A urine output of 20 mL/hr is below the expected range and indicates potential renal failure, requiring immediate intervention. In postoperative patients, a urine output less than 30 mL/hr suggests inadequate renal perfusion, a concern that needs prompt attention to prevent renal complications. The heart rate of 110/min, temperature of 37.4°C (99.3°F), and respiratory rate of 18/min are within normal ranges for a postoperative client and do not indicate immediate issues.
A nurse is reviewing the medical history of a client who has angina. What risk factor should the nurse identify?
- A. Hyperlipidemia.
- B. COPD.
- C. Seizure disorder.
- D. Hyponatremia.
Correct Answer: A
Rationale: The correct answer is A, Hyperlipidemia. Hyperlipidemia, characterized by high levels of lipids in the blood, is a well-established risk factor for the development of angina. Elevated lipid levels can lead to atherosclerosis, which narrows the arteries supplying the heart muscle with oxygenated blood, increasing the risk of angina. Choices B, C, and D are incorrect because COPD, seizure disorder, and hyponatremia are not directly associated with an increased risk of angina.
A nurse is caring for a client who has chronic kidney disease and reports nausea. The nurse should identify that this client is at risk for which of the following imbalances?
- A. Metabolic alkalosis
- B. Metabolic acidosis
- C. Respiratory alkalosis
- D. Respiratory acidosis
Correct Answer: B
Rationale: The correct answer is B: Metabolic acidosis. Clients with chronic kidney disease are at risk for metabolic acidosis because the kidneys are unable to effectively excrete acids, leading to an accumulation of acid in the body. This metabolic imbalance can result in symptoms like nausea. Choices A, C, and D are incorrect. Metabolic alkalosis is not typically associated with chronic kidney disease. Respiratory alkalosis is more commonly seen in conditions such as hyperventilation. Respiratory acidosis, on the other hand, is often linked to conditions affecting the lungs or respiratory system, not primarily kidney disease.