Nokea
Digoxin (Lanoxin) and furosemide (Lasix) are ordered for a client who has congestive heart failure. Which of the following would the nurse also expect to be ordered for this client?
- A. Potassium
- B. Calcium
- C. Aspirin
- D. Coumadin
Correct Answer: A
Rationale: Furosemide, a diuretic, can cause potassium loss, leading to hypokalemia, which increases the risk of digoxin toxicity. Potassium supplements are often ordered to maintain normal levels.
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During cardiopulmonary resuscitation (CPR), the nurse compresses the chest of an adult victim at which rate?
- A. No less than 15 compressions per minute
- B. No less than 40 compressions per minute
- C. No less than 80 compressions per minute
- D. No less than 100 compressions per minute
Correct Answer: D
Rationale: Adult CPR requires 100-120 compressions per minute to restore circulation effectively.
Please indicate with an X the best anatomic area for the nurse to auscultate mitral valve sounds.
- A. Apex of the heart
- B. Second right intercostal space
- C. Second left intercostal space
- D. Lower left sternal border
Correct Answer: A
Rationale: Mitral valve sounds are best heard at the apex (fifth intercostal space, midclavicular line).
The nurse is observing a client who is learning to perform Buerger-Allen exercises. The nurse knows that the client is performing these exercises correctly when the client is observed doing what?
- A. Alternately dorsiflexing and plantar flexing the feet while the legs are elevated
- B. Massaging the legs beginning at the feet and moving toward the heart
- C. Alternately walking short distances and resting with the legs elevated
- D. Elevating the legs, then dangling them, and then lying flat for three minutes in each position
Correct Answer: D
Rationale: Buerger-Allen exercises involve elevating the legs to promote arterial emptying, dangling to promote filling, and lying flat to rest, performed in cycles to improve circulation.
Which assessment finding should signal the nurse to withhold applying the client's nitroglycerin patch and notify the physician?
- A. The pressure of 99.8°F (37.6°C)
- B. Respiratory rate of 24 breaths/minute at rest
- C. Apical heart rate of 90 beats/minute
- D. Blood pressure of 94/62 mm Hg
Correct Answer: D
Rationale: A blood pressure of 94/62 mm Hg indicates hypotension, a contraindication for nitroglycerin, which can further lower blood pressure.
When auscultating the client's heart and breath sounds during a routine shift assessment, which action by the nurse is most appropriate?
- A. Asking the client to hold the breath
- B. Using the bell of the stethoscope
- C. Positioning the client flat in bed
- D. Locating the xiphoid process
Correct Answer: B
Rationale: The bell of the stethoscope is best for low-pitched heart sounds in pericarditis.