Nokea
An adult who has gastroenteritis and is on digitalis ha lab values of: K 3.2 mEq/L, Na 136 mEq/L, Ca 8.8 mg/dl, and Cl 98 mEq/L. the nurse puts which of the following on the client's plan of care?
- A. Stop digitalis therapy
- B. Observe for trousseau's and chovestek's
- C. Avoid foods rich in potassium signs
- D. Observe for digitalis toxicity
Correct Answer: C
Rationale: The client's low potassium level (K 3.2 mEq/L) is a cause for concern, especially in a patient on digitalis therapy. Digitalis (such as digoxin) can potentiate the effects of hypokalemia, leading to an increased risk of digitalis toxicity. Therefore, in this scenario, it is important to avoid foods rich in potassium to prevent further lowering of the potassium level. It is essential to address the electrolyte imbalance promptly to prevent potential complications related to digitalis therapy.
You may also like to solve these questions
A 34 year old male client is diagnosed with encephalitis. Medication has been started for him and he is receiving nursing care. Which of the ff nursing interventions are the most critical for such a client? Choose all that apply
- A. Measuring fluid intake and output
- B. Evaluating the clients ventilation capacity and lung sound frequently
- C. Observing closely for signs of respiratory distress
- D. Administering an indwelling urethral catheter
Correct Answer: B
Rationale: B. Evaluating the client's ventilation capacity and lung sounds frequently is crucial in encephalitis because the inflammation of the brain can affect the respiratory center, leading to respiratory compromise. Any changes in ventilation capacity or abnormal lung sounds should be addressed immediately to prevent respiratory distress.
Treat ventricular hypertrophy of endocarditis. 108 All the following are examples of Acyanotic heart defects Except :
- A. PDA
- B. ASD
- C. TOF
- D. VSD
Correct Answer: C
Rationale: Ventricular hypertrophy of endocarditis is a cardiac condition resulting from inflammation and infection of the endocardium along with hypertrophy of the ventricular walls. It requires specific treatment with appropriate antibiotics to manage the infection and inflammation. TOF (Tetralogy of Fallot) is a cyanotic heart defect characterized by four specific heart abnormalities (pulmonary valve stenosis, overriding aorta, VSD, and right ventricular hypertrophy). The question asks for an example of an acyanotic heart defect, where blood can flow through the heart without mixing poorly oxygenated and well-oxygenated blood. PDA (Patent Ductus Arteriosus), ASD (Atrial Septal Defect), and VSD (Ventricular Septal Defect) are all examples of acyanotic heart defects as they do not cause a mixing of oxygenated and deoxygenated blood.
What term describes irregular areas of deep blue pigmentation seen predominantly in newborns of African, Asian, Native American, or Hispanic descent?
- A. Acrocyanosis
- B. Erythema toxicum
- C. Mongolian spots
- D. Harlequin color changes
Correct Answer: C
Rationale: Mongolian spots are irregular areas of deep blue pigmentation commonly seen in newborns of African, Asian, Native American, or Hispanic descent. They are flat, benign, and usually appear on the lower back or buttocks, but can also occur on other parts of the body. Mongolian spots are caused by pigment that is trapped deep in the layers of the skin and tend to fade over time, usually by the age of 5 or 6, although they may persist into adulthood in some cases. It is important for healthcare providers to be aware of Mongolian spots to differentiate them from other skin conditions and provide reassurance to parents.
The nurse has given medication instruction to the client receiving phenyton (Dilantin). The nurse determines that the client has an adequate understanding if the client states that:
- A. "Alcohol is not contraindicated while taking this medication."
- B. "Good oral hygiene is needed, including brushing and flossing."
- C. "The medication dose may be self-adjusted depending on side effects."
- D. "The morning dose of the medication should be taken before a serum drug level is drawn."
Correct Answer: B
Rationale: Phenytoin (Dilantin) can cause gingival hyperplasia, a side effect manifested by overgrowth of the gums. To help prevent this side effect, patients taking phenytoin should maintain good oral hygiene practices, including regular brushing and flossing. This statement shows an understanding of the importance of oral care while on phenytoin therapy, making it the correct answer choice.
A client with Hashimoto's thyroiditis and a history of two myocardial infarctions and coronary artery disease is to receive levothyroxine (Synthroid). Because of the client's cardiac history, the nurse would expect that the client's initial dose for the thyroid replacement would be which of the following?
- A. 25 g/day, initially
- B. Delayed until after thyroid surgery
- C. 100 g/day, initially
- D. Initiated before thyroid surgery
Correct Answer: A
Rationale: In a client with a history of two myocardial infarctions and coronary artery disease, initiating levothyroxine therapy with a low starting dose of 25 mcg/day is recommended. Thyroid hormone replacement therapy can potentially worsen underlying cardiac conditions, so a cautious approach is necessary. The dose may be gradually titrated upwards based on thyroid function tests and the client's response. Delaying treatment until after thyroid surgery (option B) is not necessary in this scenario if the client requires thyroid hormone replacement. Initiating levothyroxine before thyroid surgery (option D) is not relevant to the given clinical situation. Starting with a higher dose of 100 mcg/day (option C) may pose a higher risk of cardiac complications in this client with a cardiac history.