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A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 60/min
- B. Respiratory rate of 16/min
- C. Sodium level of 138 mEq/L
- D. Weight gain of 1.5 kg (3.3 lb) in 24 hours
Correct Answer: D
Rationale: The correct answer is D. A weight gain of 1.5 kg (3.3 lb) in 24 hours can indicate fluid retention and worsening heart failure in clients taking digoxin. This rapid weight gain could be due to fluid accumulation, a common sign of heart failure exacerbation. Reporting this finding to the provider is crucial for prompt intervention. Choices A, B, and C are within normal ranges and not directly indicative of worsening heart failure in this context, making them less urgent to report compared to the significant weight gain.
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A nurse is caring for a client who has heart failure and a prescription for furosemide. Which of the following findings should the nurse identify as an indication that the medication is effective?
- A. Increased shortness of breath.
- B. Decreased peripheral edema.
- C. Increased jugular venous distention.
- D. Increased heart rate.
Correct Answer: B
Rationale: The correct answer is B: Decreased peripheral edema. Furosemide is a diuretic that helps in reducing fluid overload in clients with heart failure by increasing urine output. A decrease in peripheral edema indicates that the medication is effectively removing excess fluid from the body. Choices A, C, and D are incorrect because they do not indicate an improvement in the client's condition. Increased shortness of breath, increased jugular venous distention, and increased heart rate are all signs of worsening heart failure and would not be expected findings when furosemide is effective.
A client with a new prescription for furosemide should increase intake of which of the following?
- A. You should take this medication on an empty stomach.
- B. You should increase your intake of potassium-rich foods.
- C. You should take this medication at bedtime.
- D. You should avoid taking this medication with food.
Correct Answer: B
Rationale: The correct answer is B: 'You should increase your intake of potassium-rich foods.' Furosemide is a potassium-wasting diuretic, which means it can lead to low potassium levels in the body. Increasing intake of potassium-rich foods helps counteract this effect. Choices A, C, and D are incorrect because furosemide should not necessarily be taken on an empty stomach, at bedtime, or specifically avoided with food.
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.
A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take?
- A. Insert the catheter 7.5 cm (3 in) into the urethra.
- B. Insert the catheter until urine flow is established.
- C. Cleanse the catheter with sterile water before insertion.
- D. Insert the catheter 5 cm (2 in) into the urethra.
Correct Answer: B
Rationale: The correct action for the nurse is to insert the catheter until urine flow is established. This helps ensure proper placement and reduces the risk of trauma. Choice A (7.5 cm) and Choice D (5 cm) provide specific measurements that may not be appropriate for all individuals as catheter insertion depth can vary. Choice C is incorrect as catheters should be cleansed with an appropriate solution such as sterile saline, not sterile water.
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.