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A nurse is providing discharge teaching to a client who has a new prescription for digoxin. Which of the following instructions should the nurse include?
- A. Take this medication at bedtime.
- B. Take your pulse before taking this medication.
- C. Avoid eating foods high in potassium.
- D. Take this medication with an antacid.
Correct Answer: B
Rationale: The correct instruction for the nurse to include is to advise the client to take their pulse before taking digoxin. This is important to monitor for bradycardia, a potential side effect of the medication. Option A is incorrect because digoxin is usually taken in the morning. Option C is unrelated to digoxin therapy, as high potassium foods are usually restricted in clients taking potassium-sparing diuretics. Option D is incorrect because digoxin should not be taken with antacids as they can affect its absorption.
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A client sustained a major burn over 20% of the body. What intervention should the nurse implement to meet the client's nutritional needs?
- A. Keep track of calorie intake for food and beverages.
- B. Provide a low-protein, high-carbohydrate diet.
- C. Schedule meals at 6-hour intervals.
- D. Provide a high-protein, high-calorie diet.
Correct Answer: D
Rationale: The correct answer is to provide a high-protein, high-calorie diet for a client with major burns. This type of diet is essential to support healing and recovery. High-protein intake is crucial as it helps in tissue repair and wound healing, while high-calorie intake is necessary to meet the increased metabolic demands of the body during the healing process. Keeping track of calorie intake (Choice A) is important but doesn't address the specific needs of a burn patient. Providing a low-protein, high-carbohydrate diet (Choice B) is not suitable for burn patients as they require adequate protein for wound healing. Scheduling meals at 6-hour intervals (Choice C) may be helpful for maintaining a consistent eating schedule, but it is not as crucial as providing the correct high-protein, high-calorie diet.
During a change-of-shift report, a nurse is receiving information about an adult female client who is postoperative. Which of the following client information should the nurse report?
- A. The client's oxygen saturation is 95%
- B. The client's blood pressure is 110/70 mm Hg
- C. The client has a temperature of 36.8°C (98.2°F)
- D. The client's heart rate is 88/min
Correct Answer: B
Rationale: The correct answer is B because a blood pressure of 110/70 mm Hg is within the normal range and stable. Reporting this information is crucial to monitor the client's condition postoperatively. Oxygen saturation of 95% is acceptable, a temperature of 36.8°C (98.2°F) is normal, and a heart rate of 88/min is within the expected range for an adult female client, so these values do not raise concerns that require immediate reporting.
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.
A nurse is caring for a client who is 24 hr postpartum and is breastfeeding her newborn. The client asks the nurse to warm up seaweed soup that her partner brought for her. Which of the following responses should the nurse make?
- A. Does the doctor know you are eating that?
- B. Why are you eating seaweed soup?
- C. Of course, I will heat that up for you.
- D. The hospital food is more nutritious.
Correct Answer: C
Rationale: Respecting cultural preferences and providing client-centered care promotes trust.
A nurse is caring for a client who speaks a language different from the nurse. Which of the following actions should the nurse take?
- A. Request an interpreter of a different sex from the client
- B. Request a family member or friend to interpret information for the client
- C. Direct attention toward the interpreter when speaking to the client
- D. Review the facility policy about the use of an interpreter
Correct Answer: D
Rationale: The correct action for the nurse to take when caring for a client who speaks a different language is to review the facility policy about the use of an interpreter. This ensures compliance with best practices for communication when using interpreters, maintaining accuracy and confidentiality. Requesting an interpreter of a different sex from the client (Choice A) is not relevant to effective communication. Asking a family member or friend to interpret (Choice B) can lead to misinterpretation or breach of confidentiality. Directing attention toward the interpreter (Choice C) is not as crucial as understanding the facility's policy on interpreter use.