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An elderly client with depression, diabetes mellitus, and heart failure has received a new digoxin prescription for daily use. Which client assessment indicates that the nurse should follow up on serum digoxin levels frequently?
- A. Apical heart rate is 62/min
- B. Blood sugar level is 240 mg/dL (13.3 mmol/L)
- C. Client is taking 20 mg fluoxetine daily
- D. Serum creatinine is 2.3 mg/dL (203 µmol/L)
Correct Answer: D
Rationale: Elevated serum creatinine (2.3 mg/dL) indicates renal impairment, which can lead to digoxin accumulation, necessitating frequent monitoring.
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A client 4 days post colostomy is preparing to be discharged home. Which findings are concerning and should be further investigated? Select all that apply.
- A. Client states, 'I will need home health to empty the pouch.'
- B. Client states, 'There is a little gas in the colostomy bag.'
- C. No bowel sounds are present and the client reports nausea
- D. Skin surrounding the stoma is red and excoriated
- E. Stoma is red, edematous, and smaller than the previous day
Correct Answer: C,D,E
Rationale: Absent bowel sounds with nausea suggest obstruction, red/excoriated skin indicates irritation, and a shrinking stoma may signal complications. Gas is normal, and needing home health is not inherently concerning.
To prevent keratitis in an unconscious client, the nurse should apply moisturizing ointment to the
- A. Finger and toenail quicks
- B. Eyes
- C. Perianal area
- D. External ear canals
Correct Answer: B
Rationale: Eyes. Keratitis is a corneal ulcer or abrasion. Keratitis is caused by exposure and requires application of moisturizing ointment to the exposed cornea and a plastic bubble shield or eye patch.
A client is able to partially bear weight and follow the nurse's instructions. Which would be the most appropriate method for the nurse to use to safely transfer this client?
- A. 1-person stand and pivot with gait belt and walker
- B. 1-person standby assist with walker
- C. 2-person motorized stand-assist lift
- D. 2-person stand and pivot with gait belt and walker
Correct Answer: A
Rationale: A 1-person stand and pivot with a gait belt and walker is appropriate for a client who can partially bear weight and follow instructions. Other methods are either insufficient or overly complex.
The parent of an 8-year-old client asks the nurse for guidance on how to help the client cope with the recent death of the other parent. When developing a response to the parent, the nurse considers that a school-aged child is most likely to do what?
- A. React anxiously to altered daily routines
- B. Realize that death eventually affects everyone
- C. Think about the religious or spiritual aspects of death
- D. Understand that death is permanent but be curious about it
Correct Answer: D
Rationale: School-aged children (around 8 years old) typically understand death's permanence and may exhibit curiosity about it, which can guide coping strategies. A is more common in younger children. B and C are more typical of adolescents, who have more abstract thinking.
The nurse is planning a staff education program about intimate partner violence. Which of the following information should the nurse include? Select all that apply.
- A. Intimate partner violence is most common in high-income families.
- B. Intimate partner violence is rare in same-sex partnerships.
- C. The abusive partner often demonstrates jealousy and possessiveness.
- D. Victims may not leave due to financial concerns or fear of harm by the abuser.
- E. Violence against a female often intensifies during pregnancy.
Correct Answer: C,D,E
Rationale: Jealousy/possessiveness, barriers to leaving (financial/fear), and increased violence during pregnancy are accurate. Violence is not limited to high-income families and occurs in same-sex partnerships.