Nokea
A nurse is caring for a client who has a prescription for furosemide. Which of the following findings should the nurse identify as an indication that the medication is effective?
- A. Weight loss of 0.5 kg (1.1 lb) in 24 hours.
- B. Increased urinary output.
- C. Blood pressure of 118/78 mm Hg.
- D. Decreased peripheral edema.
Correct Answer: A
Rationale: The correct answer is A. Weight loss of 0.5 kg (1.1 lb) in 24 hours is an indication that furosemide is effectively reducing fluid retention. This medication works by promoting diuresis, resulting in increased urine output, which could lead to weight loss. While increased urinary output (choice B) is a common effect of furosemide, weight loss is a more specific indicator of its effectiveness. Blood pressure (choice C) and decreased peripheral edema (choice D) can be influenced by various factors and are not direct indicators of furosemide's effectiveness in reducing fluid retention.
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A client with diabetes mellitus is receiving education from a nurse on preventing long-term complications. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will keep my blood glucose levels within the target range.
- B. I will check my feet daily for any open sores or wounds.
- C. I will monitor my blood pressure regularly.
- D. I will consume foods that are high in fiber.
Correct Answer: B
Rationale: The correct answer is B: 'I will check my feet daily for any open sores or wounds.' This statement shows an understanding of the importance of foot care in preventing complications like diabetic foot ulcers. Monitoring blood glucose levels (choice A) is crucial but not directly related to foot care. Monitoring blood pressure (choice C) is important for overall health but does not specifically address preventing long-term complications of diabetes. Consuming foods high in fiber (choice D) is beneficial for managing blood sugar levels but does not directly address preventing foot complications.
A nurse working in a rehabilitation facility is developing a discharge plan for a client who has left-sided hemiplegia. Which of the following actions is the nurse's priority?
- A. Consult with a case manager regarding insurance coverage.
- B. Counsel caregivers on respite care options.
- C. Ensure that the client has a referral for physical therapy.
- D. Refer the client to a local stroke support group.
Correct Answer: C
Rationale: The correct answer is C: 'Ensure that the client has a referral for physical therapy.' For a client with left-sided hemiplegia, physical therapy is crucial in restoring function and mobility. It is the nurse's priority to ensure the client receives the necessary rehabilitation services. Consulting with a case manager about insurance coverage (Choice A) is important but not the priority at this stage. Counseling caregivers on respite care options (Choice B) and referring the client to a local stroke support group (Choice D) are also valuable but not as essential as ensuring the client has access to physical therapy for rehabilitation.
A client with heart failure is receiving discharge teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I should weigh myself once a week.
- B. I should limit my fluid intake to 1 liter per day.
- C. I should report a weight gain of 2 pounds in one day.
- D. I should reduce my protein intake to prevent fluid retention.
Correct Answer: C
Rationale: The correct answer is C. Reporting a sudden weight gain of 2 pounds in one day is crucial in managing heart failure because it can indicate fluid retention, a common symptom in heart failure. Option A is incorrect as weighing oneself once a week may not provide timely information about fluid retention. Option B is incorrect because fluid intake restriction is individualized and generally involves more specific guidance. Option D is incorrect as protein intake is important but reducing it solely to avoid fluid retention is not the primary focus in heart failure management.
A nurse is preparing to administer a controlled substance. Which of the following actions should the nurse take?
- A. Witness the waste of the controlled substance by another nurse
- B. Dispose of the controlled substance by yourself
- C. Leave the controlled substance in the client's room for later use
- D. Document the administration and sign off at the end of the shift
Correct Answer: A
Rationale: The correct action for the nurse preparing to administer a controlled substance is to witness the waste of the controlled substance by another nurse. This practice is crucial to prevent misuse and ensure accurate documentation. Choice B is incorrect because disposing of the controlled substance by oneself without proper witnessing is not in accordance with safety protocols. Choice C is incorrect as leaving a controlled substance unattended in a client's room poses risks of diversion or unauthorized access. Choice D is incorrect because documenting the administration and signing off at the end of the shift is important but does not specifically address the issue of witnessing the waste of a controlled substance, which is a critical step in ensuring proper handling and accountability.
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.