Nokea
A nurse is monitoring laboratory values for a client who has chronic heart failure and is receiving digoxin. Which of the following values should the nurse report to the provider?
- A. Sodium 1.38 mEq/dL
- B. Magnesium 1.5 mEq/L
- C. BUN level 10 mg/dL
- D. Potassium 2.9 mEq/L
Correct Answer: D
Rationale: The correct answer is D: Potassium 2.9 mEq/L. Low potassium levels can predispose the client to digoxin toxicity, leading to potentially life-threatening arrhythmias. Hypokalemia increases the risk of digoxin binding to cardiac tissue, enhancing its toxic effects. The nurse should report this value to the provider immediately for prompt intervention to prevent complications.
Incorrect Choices:
A: Sodium 1.38 mEq/dL - Low sodium levels are not directly related to digoxin toxicity.
B: Magnesium 1.5 mEq/L - While magnesium levels are important for cardiac function, they are not as directly linked to digoxin toxicity as potassium.
C: BUN level 10 mg/dL - BUN levels are not specific indicators of digoxin toxicity.
Summary: Potassium levels are crucial to monitor in clients taking digoxin due to the risk of toxicity. Sodium, magnesium, and BUN levels are important but not as
You may also like to solve these questions
A client who has active tuberculosis and is taking rifampin reports that his urine and sweat have developed a red tinge. Which of the following actions should the nurse take?
- A. Check the client's liver function test results.
- B. Instruct the client to increase his fluid intake.
- C. Document this as an expected finding.
- D. Prepare the client for dialysis.
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Document this as an expected finding. Rifampin is known to cause harmless discoloration of bodily fluids like urine and sweat. This is a common side effect and does not indicate any serious issues. The nurse should document this finding to track the client's response to the medication and educate the client about it.
Summary of Incorrect Choices:
A: Checking liver function test results is not necessary for the red discoloration caused by rifampin.
B: Increasing fluid intake will not resolve the red tinge as it is a known side effect of rifampin.
D: Dialysis is not indicated for the harmless discoloration caused by rifampin.
A nurse is providing teaching to a client who has a new prescription for clozapine. Which of the following statements should the nurse include in the teaching?
- A. Diarrhea is a common adverse effect of this medication.
- B. Ringing in the ears is an expected adverse effect of this medication.
- C. Notify your provider if you develop a fever while taking this medication.
- D. You might experience weight loss while taking this medication.
Correct Answer: C
Rationale: The correct answer is C: Notify your provider if you develop a fever while taking this medication. This is important because clozapine can cause a serious condition called agranulocytosis, which can lead to a fever. The nurse should emphasize the significance of monitoring for fever and promptly notifying the healthcare provider. Choice A is incorrect because diarrhea is not a common adverse effect of clozapine. Choice B is incorrect as ringing in the ears is not an expected adverse effect. Choice D is incorrect because weight gain, not weight loss, is a common side effect of clozapine.
A nurse is providing teaching to a client who has a new prescription for theophylline, a sustained-released capsule. Which of the following statements by the client indicates an understanding of the teaching?
- A. I can take my medication in the morning with my coffee.
- B. I may sprinkle the medication in applesauce.
- C. I should limit my fluid intake while on this medication.
- D. I will need to have blood levels drawn.
Correct Answer: D
Rationale: Answer D is correct because monitoring blood levels is crucial for theophylline therapy due to its narrow therapeutic range. Regular monitoring helps ensure the drug is at a safe and effective level in the body. Taking the medication with food or fluids, as indicated in choices A and C, can affect its absorption or metabolism, leading to suboptimal effects or toxicity. Sprinkling the medication in applesauce, as in choice B, can alter the drug's sustained-release mechanism, causing rapid release and possible adverse effects. Therefore, choice D is the best option for ensuring theophylline therapy's safety and efficacy.
A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse take?
- A. Apply firm pressure to the injection site following administration
- B. Administer the medication into the client's muscle
- C. Expel the air bubble from the syringe prior to injection
- D. Insert the syringe needle halfway into the client's skin
Correct Answer: A
Rationale: Correct Answer: A: Apply firm pressure to the injection site following administration.
Rationale: Applying firm pressure to the injection site following administration of enoxaparin helps minimize the risk of bleeding, as enoxaparin is an anticoagulant medication. This pressure promotes clot formation and reduces the likelihood of bruising or hematoma formation at the injection site.
Summary of other choices:
B: Administer the medication into the client's muscle - Incorrect. Enoxaparin is a subcutaneous medication, not meant for intramuscular administration.
C: Expel the air bubble from the syringe prior to injection - Good practice but not directly related to the administration of enoxaparin.
D: Insert the syringe needle halfway into the client's skin - Incorrect. The needle should be fully inserted for proper subcutaneous injection.
A nurse is assessing a client's IV infusion site and notes that the site is cool and edematous. Which of the following actions should the nurse take?
- A. Slow the IV solution rate
- B. Initiate a new IV distal to the initial site
- C. Maintain the extremity below the level of the heart
- D. Apply a warm, moist compress
Correct Answer: D
Rationale: The correct action is to apply a warm, moist compress (Choice D). This helps improve circulation and reduce edema by promoting vasodilation and enhancing tissue perfusion. Cooling and edematous IV sites indicate impaired circulation, which can lead to complications like phlebitis. Slowing the IV rate (Choice A) may not address the underlying issue. Initiating a new IV distal to the initial site (Choice B) may not improve circulation in the affected area. Maintaining the extremity below heart level (Choice C) can worsen edema.