Nokea
Before administering a client's morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:
- A. Record the pulse rate and administer the medication
- B. Administer the medication and monitor the heart rate
- C. Withhold the medication and notify the doctor
- D. Withhold the medication until the heart rate increases
Correct Answer: C
Rationale: A pulse rate below 60 bpm is a contraindication for digoxin administration due to the risk of worsening bradycardia, so the nurse should withhold the dose and notify the physician.
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A nurse creates a care plan for a client diagnosed with a cerebellar brain tumor. The correct nursing diagnosis for this client is 'Client at risk for injury related to
- A. impaired balance.'
- B. decreased visual acuity.'
- C. decreased level of consciousness.'
- D. impaired ability to make decisions.'
Correct Answer: A
Rationale: Cerebellar tumors impair coordination and balance, increasing fall risk, making 'impaired balance' the most relevant diagnosis.
The nurse is administering an intermittent tube feeding to a client through a nasogastric tube. Which of the following positions is optimal for tube feedings?
- A. The head of the bed is elevated to 45°.
- B. The head of the bed is elevated to 90°.
- C. The head of the bed is elevated to 30°.
- D. The head of the bed is flat with the client supine.
Correct Answer: A
Rationale: Elevating the head of the bed to 45° (A) during tube feedings reduces the risk of aspiration and promotes digestion. A 90° elevation (B) is excessive, 30° (C) is insufficient, and a flat position (D) increases aspiration risk.
A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. The nurse's response is based on the knowledge that hemodialysis works by:
- A. Passing water through a dialyzing membrane
- B. Eliminating plasma proteins from the blood
- C. Lowering the pH by removing nonvolatile acids
- D. Filtering waste through a dialyzing membrane
Correct Answer: D
Rationale: Hemodialysis filters waste products and excess fluids through a dialyzing membrane, mimicking kidney function.
The nurse is caring for an infant receiving intravenous fluid. Signs of fluid overload in an infant include:
- A. Swelling of the hands and increased temperature
- B. Increased heart rate and increased blood pressure
- C. Swelling of the feet and increased temperature
- D. Decreased heart rate and decreased blood pressure
Correct Answer: B
Rationale: Fluid overload in infants can cause increased heart rate and blood pressure due to increased intravascular volume.
The nurse is assessing a client with a history of diabetes mellitus who is admitted with diabetic ketoacidosis (DKA). Which of the following findings would the nurse expect?
- A. Slow, shallow respirations.
- B. Fruity breath odor.
- C. Bradycardia.
- D. Hypotension.
Correct Answer: B
Rationale: fruity breath odor is a classic sign of DKA due to the presence of acetone