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A nurse is caring for a newly admitted patient who will receive Digoxin to treat cardiac dysrhythmia. The patient takes hydrochlorothiazide and reports regular use of OTC laxatives. Before administering the first dose of Digoxin, the nurse will review the patient's electrolyte levels with careful attention to which electrolytes?
- A. Calcium and magnesium.
- B. Potassium and chloride.
- C. Potassium and magnesium.
- D. Sodium and calcium.
Correct Answer: C
Rationale: The correct answer is C: Potassium and magnesium. Digoxin can cause toxicity in patients with low potassium or low magnesium levels, which can be exacerbated by the use of hydrochlorothiazide and OTC laxatives. Monitoring potassium and magnesium levels is crucial to prevent adverse effects such as cardiac dysrhythmias. Calcium and magnesium (choice A) are important electrolytes, but potassium is more critical in the context of Digoxin therapy. Potassium and chloride (choice B) are both important electrolytes, but magnesium should also be monitored. Sodium and calcium (choice D) are not the most relevant electrolytes to monitor in this situation.
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The nurse is helping develop a plan of care for a patient that has advanced Alzheimer's disease. The patient will be taking a new medication. Which is a realistic goal for this patient?
- A. Exhibit ability to provide self-care.
- B. Show improved memory for recent events.
- C. Receive appropriate assistance for care needs.
- D. Demonstrate improved cognitive function.
Correct Answer: C
Rationale: The correct answer is C: Receive appropriate assistance for care needs. For a patient with advanced Alzheimer's disease, improving memory or cognitive function is unrealistic due to the progressive nature of the disease. Providing self-care may also be beyond their ability. Setting a goal for the patient to receive appropriate assistance for care needs is realistic and important for maintaining their quality of life and safety. This goal focuses on ensuring the patient's basic needs are met and promoting their overall well-being despite their cognitive decline. It prioritizes practical support and enhances the patient's quality of life.
The emergency department nurse is administering IV lidocaine to patients. What adverse effect of lidocaine therapy should the nurse assess for?
- A. Tinnitus.
- B. Dizziness.
- C. Dysphagia.
- D. Excessive bruising.
Correct Answer: B
Rationale: The correct answer is B: Dizziness. Lidocaine is a local anesthetic that can cause dizziness as an adverse effect due to its effect on the central nervous system. The nurse should assess for dizziness as it can impact the patient's safety and may indicate toxicity. Tinnitus (A) is a potential side effect of lidocaine, but it is less common than dizziness. Dysphagia (C) is not a typical adverse effect of lidocaine. Excessive bruising (D) is not associated with lidocaine therapy.
A 70-year-old patient has just received a drug that can cause sedation. What would be the priority nursing diagnosis for this patient?
- A. Deficient Knowledge, unfamiliar with drug therapy.
- B. Ineffective health maintenance, need for medication.
- C. Risk for injury, related to adverse effect of the drug.
- D. Noncompliance, cost of the drug.
Correct Answer: C
Rationale: The correct answer is C: Risk for injury, related to adverse effect of the drug. This is the priority nursing diagnosis because the patient, being 70 years old and receiving a sedating drug, is at an increased risk for falls and other injuries due to sedation. It is crucial for the nurse to monitor the patient closely for signs of sedation and take appropriate measures to prevent potential harm.
Choice A (Deficient Knowledge) is not the priority as the immediate concern is the risk of injury. Choice B (Ineffective health maintenance) focuses on the need for medication, not the potential risk of injury. Choice D (Noncompliance) is not relevant in this situation as it pertains to the cost of the drug, not the immediate safety of the patient.
Vitamin D plays an important part in the absorption of calcium by the body. Where is vitamin D activated into a form that promotes calcium absorption?
- A. Small intestine.
- B. Vitamin D is not activated into another form.
- C. Kidneys.
- D. Large intestine.
Correct Answer: C
Rationale: The correct answer is C: Kidneys. Vitamin D undergoes two hydroxylation steps for activation - first in the liver and then in the kidneys. The final active form of vitamin D, calcitriol, is produced in the kidneys. Calcitriol promotes the absorption of calcium in the intestines. The small intestine (Choice A) is where calcium is absorbed, but vitamin D is activated in the kidneys. Vitamin D does undergo activation into another form as mentioned above, so choice B is incorrect. The large intestine (Choice D) is primarily involved in water absorption, not vitamin D activation.
A home care nurse administers oral morphine to the patient with cancer pain. When will the nurse expect the medication to reach peak activity?
- A. 45 minutes.
- B. 10 minutes.
- C. 30 minutes.
- D. 60 minutes.
Correct Answer: A
Rationale: The correct answer is A: 45 minutes. Oral morphine typically reaches peak activity within 30-60 minutes after administration due to its absorption rate. After ingestion, the medication passes through the stomach and intestines before entering the bloodstream, which takes time. Choice B (10 minutes) is too soon for peak activity. Choice C (30 minutes) is close but not the peak time frame. Choice D (60 minutes) is too late for peak activity.