Nokea
A nurse is preparing to administer digoxin orally to a client. Identify the sequence of steps the nurse should take (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)
- A. Remove the medication from the dispensing system.
- B. Compare the client's wristband to the medication administration record.
- C. Document administration of the medication.
- D. Open the medication package.
- E. Obtain the client's apical heart rate.
Correct Answer: E,A,B,D,C
Rationale: The sequence ensures safety and accuracy: checking the apical heart rate first prevents administration if contraindicated; removing the medication , verifying patient identity , opening the package , and documenting follow standard medication administration protocols.
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A client with a renal calculus reports severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?
- A. Impaired renal function related to pain.
- B. Acute pain related to renal calculus.
- C. Risk for aspiration related to vomiting.
- D. Nutritional deficit related to nausea.
Correct Answer: C
Rationale: Risk for aspiration is the highest priority due to the immediate threat of airway obstruction from vomiting.
The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendation should the nurse encourage the client to follow?
- A. Increase Intake of potassium rich foods such as bananas or cantaloupe.
- B. Restrict protein intake by limiting meats and other high protein foods.
- C. Limit oral fluid intake to 500 mL/day.
- D. Increase intake of high fiber foods, such as bran cereal.
Correct Answer: B
Rationale: Restricting protein reduces kidney workload and proteinuria, preserving function in glomerulonephritis.
The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes vital signs of a heart rate of 140 beats/minute, a respiratory rate of 26 breaths/minute, and a blood pressure of 140/90 mm Hg. Which intervention is most important for the nurse to implement?
- A. Administer IV fluid bolus as prescribed by the healthcare provider.
- B. Encourage the client to splint the Incision with a pillow to cough and deep breathe.
- C. Medicate for pain and monitor vital signs according to protocol.
- D. Apply oxygen at 10 L/minute via non-rebreather mask and monitor pulse oximeter.
Correct Answer: C
Rationale: Pain medication addresses tachycardia and tachypnea likely caused by postoperative pain, stabilizing vital signs.
Orders
Laboratory Results
Day 1, 1000
Serum uric acid, blood urea nitrogen (BUN), creatinine (Cr)
X-ray of right foot
Day 1, 1015
Acetaminophen 650 mg PO now
Based on the client's laboratory findings, the nurse recognizes that the client is having an acute gout attack and is most at risk for SwellingBruisingInfectionInflammationRash and DiscolorationErythemaCyanosisPallorEcchymosis in his affected joint.
- A. Inflammation
- B. Discoloration
- C. Erythema Cyanosis
- D. Swelling
- E. Bruising
Correct Answer: A,B
Rationale: Inflammation and discoloration are hallmark symptoms of gout due to urate crystal-induced immune response and increased blood flow.
When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include?
- A. Eat a soft diet with increased intake of milk and milk products.
- B. Have small frequent meals and sit up for at least two hours after meals.
- C. Eat a bland diet and avoid spicy foods.
- D. Eat a high fiber diet and increase fluid intake.
Correct Answer: D
Rationale: A high-fiber diet with increased fluids promotes bowel regularity, reducing diverticulosis complications.