Nokea
A nurse is caring for a client who is experiencing an exacerbation of heart failure. Which of the following findings indicate potential improvement?
- A. Hgb 8.4 g/dL (12 to 18 g/dL)
- B. Hct 42% (37% to 47%)
- C. WBC count 9
- D. Potassium 4.3 mEq/L (3.5 to 5 mEq/L)
Correct Answer: D
Rationale: The correct answer is D: Potassium 4.3 mEq/L (3.5 to 5 mEq/L). In heart failure exacerbation, potassium levels can be affected due to medications or fluid shifts. A potassium level within the normal range indicates electrolyte balance, which is crucial for cardiac function. Hemoglobin (Choice A) and hematocrit (Choice B) are indicators of oxygen-carrying capacity and volume status, not directly related to heart failure improvement. White blood cell count (Choice C) is not specific to heart failure exacerbation. Therefore, the correct answer is D as it reflects a positive change in electrolyte balance, essential for cardiac function.
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A nurse is caring for a client who has cervical cancer and is receiving internal radiation therapy. Which of the following actions should the nurse take?
- A. Check if the radioactive device is in the correct position.
- B. Limit time for visitors to 2 hours per day.
- C. Ask visitors to remain 3 feet from the client.
- D. Keep lead-lined aprons in the client's room.
Correct Answer: A
Rationale: The correct action for the nurse to take is to check if the radioactive device is in the correct position. This is crucial to ensure that the radiation therapy is being delivered accurately and effectively. By verifying the position of the radioactive device, the nurse can prevent potential harm to the client and ensure the success of the treatment.
Choice B is incorrect because limiting visitors' time does not directly relate to the safety and effectiveness of the radiation therapy. Choice C is incorrect as asking visitors to remain 3 feet away does not address the primary concern of verifying the device's position. Choice D is also incorrect as lead-lined aprons are typically used by healthcare providers during procedures, not by the client.
A nurse is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?
- A. Move client to a double room.
- B. Use chemical restraints at bedtime.
- C. Use a bed alarm.
- D. Encourage participation in activities that provide excessive stimulation.
Correct Answer: C
Rationale: The correct answer is C: Use a bed alarm. This option promotes client safety by alerting the nurse when the client attempts to leave the bed, reducing the risk of wandering. Moving the client to a double room (A) does not address the wandering behavior. Using chemical restraints (B) is unethical and can lead to adverse effects. Encouraging excessive stimulation (D) can escalate agitation and wandering behavior.
A nurse is providing discharge teaching for a client who has heart failure and is to start therapy with digoxin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will take my digoxin if my pulse is less than 50 beats per minute.
- B. I will take this medication with fiber to prevent constipation.
- C. I will increase my dose if my vision becomes blurred.
- D. I will notify my provider if I experience muscle weakness.
Correct Answer: D
Rationale: Rationale for Correct Answer (D):
The correct answer is D because muscle weakness is a potential sign of digoxin toxicity. It is crucial for the client to notify the provider immediately to prevent serious complications. This statement indicates an understanding of the teaching regarding digoxin therapy.
Summary of Incorrect Choices:
A: Incorrect. Taking digoxin with a pulse less than 50 beats per minute can lead to bradycardia and toxicity.
B: Incorrect. Taking digoxin with fiber may decrease its absorption, reducing its effectiveness.
C: Incorrect. Blurred vision is a sign of digoxin toxicity, and the dose should be decreased, not increased.
A nurse is assessing a client who is receiving morphine for pain and has a respiratory rate of 8/min and a blood pressure of 80/50 mmHg. Which of the following medications should the nurse administer?
- A. Naloxone
- B. Promethazine
- C. Acetylcysteine
- D. Flumazenil
Correct Answer: A
Rationale: The correct answer is A: Naloxone. Naloxone is an opioid antagonist that reverses the effects of opioids like morphine, which can cause respiratory depression leading to bradypnea (slow breathing) and hypotension. In this case, the client's low respiratory rate and blood pressure indicate opioid overdose. Administering naloxone can help reverse the respiratory depression and stabilize the client's breathing and blood pressure.
Promethazine (B) is an antihistamine used for nausea and vomiting, not for opioid overdose. Acetylcysteine (C) is a mucolytic agent used for acetaminophen overdose. Flumazenil (D) is a benzodiazepine antagonist, not indicated for opioid overdose.
A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actions should the nurse take?
- A. Administer the transfusion through a 25-gauge saline lock.
- B. Hold the transfusion if the client is actively bleeding.
- C. Administer the plasma immediately after thawing.
- D. Transfuse the plasma over 4 hr.
Correct Answer: C
Rationale: The correct answer is C: Administer the plasma immediately after thawing. Fresh frozen plasma should be administered promptly after thawing to ensure optimal effectiveness and prevent clotting. Delaying administration can lead to decreased clotting factor activity. Choice A is incorrect as a larger gauge needle is typically used for plasma transfusions. Choice B is incorrect because fresh frozen plasma is often indicated for bleeding disorders, so holding the transfusion would be counterproductive. Choice D is incorrect as fresh frozen plasma is usually infused rapidly, not over 4 hours.