Nokea
Digoxin has been prescribed for a 70-year-old man who has atrial fibrillation. Which behavior indicates that the client understands the nurse's instructions about taking digoxin?
- A. The client states that he will not spend much time in the sun.
- B. The client says to the nurse, 'Is this the correct way to check my pulse? I want to do it right.'
- C. The client tells the nurse he will be very careful to sit on the edge of the bed for a few moments before standing up.
- D. The client says, 'I will not take Cialis while I am taking this medicine.'
Correct Answer: B
Rationale: Checking pulse before taking digoxin prevents administration if bradycardia is present, indicating understanding of toxicity monitoring.
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A client with acromegaly will most likely experience which symptom?
- A. Bone pain
- B. Frequent infections
- C. Fatigue
- D. Weight loss
Correct Answer: A
Rationale: Acromegaly, caused by excess growth hormone, often leads to bone pain due to bone overgrowth. Infections , fatigue , and weight loss are less specific symptoms.
The nurse is assisting a client with deep breathing and coughing exercises following abdominal surgery. What instruction is most appropriate for the nurse to give the client?
- A. Hold your breath for several seconds and then breathe out forcefully.
- B. Splint your incision while taking in deep breaths and coughing.
- C. Take deep breaths when you are moving in bed.
- D. Deep breathing exercises should be done when you are out of bed.
Correct Answer: B
Rationale: Splinting the incision reduces pain and supports effective deep breathing and coughing, preventing postoperative complications.
The nurse is assessing the client's abdomen. Which should the nurse do first?
- A. Auscultate
- B. Percuss
- C. Inspect
- D. Palpate
Correct Answer: C
Rationale: Abdominal assessment begins with inspection to observe for visible abnormalities, followed by auscultation, percussion, and palpation to avoid altering bowel sounds.
A client has a history of oliguria, hypertension, and peripheral edema.
- A. Which nutrient should be restricted in a client with oliguria, hypertension, and peripheral edema (BUN 25, K+ 0 mEq/L)?
- B. Protein.
- C. Fats.
- D. Carbohydrates.
- E. Magnesium.
Correct Answer: A
Rationale: Oliguria, hypertension, and edema suggest renal impairment, where protein restriction reduces metabolic waste (e.g., urea nitrogen) that the kidneys cannot excrete. Fats and carbohydrates are encouraged, and magnesium restriction is not indicated.
An adult who has a hiatal hernia is seen in clinic. The nurse is reviewing her care with her. Which comment by the client indicates a need for more teaching about managing her condition?
- A. I sit up for an hour after eating.
- B. I miss drinking soda, but I know it is not good for me.
- C. I like to go swimming every day.
- D. I drink hot chocolate instead of coffee.
Correct Answer: D
Rationale: Hot chocolate contains caffeine, which can relax the lower esophageal sphincter, worsening hiatal hernia symptoms. Sitting up, avoiding soda, and swimming are appropriate for management.