A nurse is caring for a client who has heart failure and a prescription for digoxin 125 mcg orally daily. Digoxin is available in 0.25 mg/tablet form. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.5
Rationale: Calculation: 125 mcg = 0.125 mg; 0.125 mg ÷ 0.25 mg/tablet = 0.5 tablets
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A nurse is caring for a client who has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?
- A. Occasional bubbling in the water-seal chamber
- B. No reports of pleuritic chest pain
- C. No tidaling in the water-seal chamber
- D. Oxygen saturation of 95%
Correct Answer: C
Rationale: Absence of tidaling indicates lung re-expansion as intrapleural pressure equalizes.
A nurse in an emergency department is planning care for a client who is having an acute myocardial infarction (MI). Which of the following medications should the nurse plan to administer after the initial acute phase to manage the client's pain and anxiety?
- A. Nitroglycerin
- B. Aspirin
- C. Oxygen
- D. Morphine
Correct Answer: D
Rationale: Morphine is used for pain/anxiety management post-MI after acute interventions.
A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following findings should the nurse identify as a potential cause for autonomic dysreflexia?
- A. The client's bladder becomes distended.
- B. The client states having a severe headache.
- C. The client states having nasal congestion.
- D. The client's blood pressure becomes elevated.
Correct Answer: A
Rationale: A distended bladder is a common cause of autonomic dysreflexia. It can trigger an exaggerated response from the autonomic nervous system, leading to a rapid increase in blood pressure.
A nurse is assessing a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?
- A. Tachypnea
- B. Hypotension
- C. Decreased level of consciousness
- D. Bilateral weakness of extremities
Correct Answer: C
Rationale: Decreased LOC is the earliest and most sensitive sign of increased ICP.
A nurse is reviewing the laboratory test results from a client who has acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?
- A. Hypophosphatemia
- B. Hypercalcemia
- C. Hyperkalemia
- D. Hypernatremia
Correct Answer: C
Rationale: Hyperkalemia is expected in AKI due to impaired renal potassium excretion.
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