Nokea
Prior to administering digoxin to a client with congestive heart failure, the nurse needs to assess:
- A. Respiratory rate for 1 minute
- B. Radial pulse for 1 minute
- C. Radial pulse for 2 minutes
- D. Apical pulse for 1 minute
Correct Answer: D
Rationale: Apical pulse should be measured for 1-minute prior to digoxin administration. Digoxin decreases the heart rate. Digoxin should be withheld if apical rates are <60 bpm or >120 bpm.
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A family is experiencing changes in their lifestyle in many ways. The invalid grandmother has moved in with them. The couple have a 2-year-old son by their marriage, and the wife has two children by her previous marriage. The older children are in high school. In applying systems theory to this family, it is important for the nurse to remember which of the following principles?
- A. The parts of a system are only minimally related.
- B. Dysfunction in one part affects every other part.
- C. A family system has no boundaries.
- D. Healthy families are enmeshed.
Correct Answer: B
Rationale: Any change in any part of the system affects all other parts.
The nurse is caring for a client post-myocardial infarction on the cardiac unit. The client is exhibiting symptoms of shock. Which clinical manifestation is the best indicator that the shock is cardiogenic rather than anaphylactic?
- A. BP 90/60
- B. Chest pain
- C. Increased anxiety
- D. Temp 98.6°F
Correct Answer: B
Rationale: Chest pain is a hallmark of cardiogenic shock due to myocardial ischemia, distinguishing it from anaphylactic shock, which typically involves urticaria or bronchospasm. Low BP (A) and anxiety (C) are common in both, and normal temperature (D) is nonspecific.
The nurse is caring for a client with a diagnosis of gestational hypertension. Which intervention is most appropriate?
- A. Monitor blood pressure
- B. Administer antihypertensives
- C. Monitor fetal heart tones
- D. All of the above
Correct Answer: D
Rationale: Gestational hypertension requires blood pressure monitoring to assess severity antihypertensives for severe hypertension and fetal heart tone monitoring to ensure fetal well-being. All interventions are appropriate.
An obstetrical client with diabetes has an amniocentesis at 28 weeks gestation. Which test indicates the degree of fetal lung maturity?
- A. Alpha-fetoprotein
- B. Estriol level
- C. Indirect Coombs
- D. Lecithin sphingomyelin ratio
Correct Answer: D
Rationale: The lecithin-sphingomyelin (L/S) ratio measures fetal lung maturity by assessing surfactant production, critical for preventing respiratory distress syndrome in preterm infants.
The obstetric client's fetal heart rate is 80-90 during the contractions. The first action the nurse should take is:
- A. Reposition the monitor
- B. Turn the client to her left side
- C. Ask the client to ambulate
- D. Prepare the client for delivery
Correct Answer: B
Rationale: A fetal heart rate of 80-90 during contractions indicates bradycardia possibly from cord compression or uteroplacental insufficiency. Turning the client to her left side improves placental perfusion and is the first action.