Nokea
If the client develops digoxin toxicity, what would the nurse expect the client to exhibit?
- A. Anorexia and nausea
- B. Dizziness and insomnia
- C. Pinpoint pupils and double vision
- D. Ringing in the ears and itchy skin
Correct Answer: A
Rationale: Digoxin toxicity commonly causes anorexia, nausea, and vomiting due to gastrointestinal effects.
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Which assessment finding would most likely indicate that a client has thrombophlebitis in the leg?
- A. Diminished pedal pulses
- B. Color changes in the extremities when elevated
- C. Red, shiny skin
- D. Coolness and pallor in the leg
Correct Answer: C
Rationale: Red, shiny skin is a common sign of thrombophlebitis due to inflammation and impaired venous return. Diminished pulses, color changes with elevation, or coolness are more indicative of arterial issues.
An adult client is admitted to the hospital with peripheral vascular disease of the lower extremities. He has several ischemic ulcers on each ankle and lower leg area. Other parts of his skin are shiny and taut with loss of hair. A primary nursing goal for this client should be to do which of the following?
- A. Increase activity tolerance
- B. Relieve anxiety
- C. Protect from injury
- D. Help build a positive body image
Correct Answer: C
Rationale: Protecting from injury is critical for a client with peripheral vascular disease and ischemic ulcers to prevent infection and further tissue damage. Other goals are secondary.
The nurse is caring for a client who is receiving heparin. What drug should be readily available?
- A. Vitamin K
- B. Caffeine
- C. Calcium gluconate
- D. Protamine sulfate
Correct Answer: D
Rationale: The antidote for heparin is protamine sulfate. Vitamin K is the antidote for warfarin. Calcium gluconate is used for magnesium sulfate overdose. Caffeine is a stimulant and not an antidote.
A prothrombin time test should be performed regularly on persons who are taking which medication?
- A. Heparin
- B. Warfarin
- C. Phenobarbital
- D. Digoxin
Correct Answer: B
Rationale: A prothrombin time test is done to determine the effectiveness of warfarin. A partial thromboplastin time test is used for heparin. Phenobarbital and digoxin do not require regular clotting tests, though serum levels may be monitored for long-term therapy.
A client has an elevated AST 24 hours following chest pain and shortness of breath. This is suggestive of which of the following?
- A. Gallbladder disease
- B. Liver disease
- C. Myocardial infarction
- D. Skeletal muscle injury
Correct Answer: C
Rationale: AST is an enzyme released in response to tissue damage. The symptoms of chest pain and shortness of breath, along with elevated AST 24 hours later, are suggestive of myocardial infarction. AST rises after a myocardial infarction but may also rise with liver damage or skeletal muscle injury. Gallbladder disease typically presents with pain in the right scapula region and would not have an elevated AST.