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Prior to his discharge from the hospital, a cardiac client is started on digoxin (Lanoxin) 25 mg po qd. The nurse initiates discharge teaching. Which of the following statements by the client would validate an understanding of his medication?
- A. I would notify my physician immediately if I experience nausea, vomiting, and double vision.'
- B. I could stop taking this medication when I begin to feel better.'
- C. I should only take the medication if my heart rate is greater than 100 bpm.'
- D. I should always take this medication with an antacid.'
Correct Answer: A
Rationale: The first signs of digoxin toxicity include abdominal pain, anorexia, nausea, vomiting, and visual disturbances. The physician should be notified if any of these symptoms are experienced. The positive inotropic effects of digoxin increase cardiac output and result in an enhanced activity tolerance. 'Feeling better' indicates the drug is working and medication therapy must be continued. Clients should be taught to take their pulse prior to taking the digoxin. If their pulse rate becomes irregular, slows significantly, or is >100 bpm the physician should be notified. Antacids decrease the effectiveness of digoxin.
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In preparation for the removal of the client's chest tubes, the nurse should instruct the client to:
- A. Breathe normally
- B. Hold his breath and bear down
- C. Take deep breaths
- D. Take shallow breaths
Correct Answer: B
Rationale: During chest tube removal, the client should hold their breath and bear down (Valsalva maneuver) to increase intrathoracic pressure, reducing the risk of air entering the pleural space.
The nurse is caring for a 6-week-old girl with meningitis. To help her develop a sense of trust, the nurse should:
- A. Give her a small soft blanket to hold
- B. Give her good perineal care after each diaper change
- C. Leave the door open to her room
- D. Pick her up when she cries
Correct Answer: D
Rationale: A soft blanket may be comforting, but it is not directed toward developing a sense of trust. Good perineal care is important, but it is not directed toward developing a sense of trust. An infant with meningitis needs frequent attention, but leaving the door open does not foster trust. Consistently picking her up when she cries will help the child feel trust in her caregivers.
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 nurse is caring for a client with a history of type 2 diabetes. The nurse should expect the client to have:
- A. Polyuria
- B. Weight loss
- C. Bradycardia
- D. Constipation
Correct Answer: A
Rationale: Type 2 diabetes causes hyperglycemia, leading to polyuria due to osmotic diuresis.
A 16-year-old client with anorexia nervosa is on an inpatient psychiatric unit. She has a fear of gaining weight and is refusing to eat sufficient amounts to maintain body weight for her age, height, and stature. To assist with the problem of powerlessness and plan for the client to no longer need to withhold food to feel in control, the nurse uses the following strategy:
- A. Establish a structured environment with routine tasks and activities. Also, serve meals at the same time each day.
- B. Distract the client during meals to get her to eat because she must take in sufficient amounts to keep from starving.
- C. Do frequent room checks to be sure that the client is not hiding food or throwing it away.
- D. Listen attentively and participate in in-depth discussions about food, because these actions may encourage her to eat.
Correct Answer: A
Rationale: Anorexia nervosa clients feel out of control. Providing a structured environment offers safety and comfort and can help them to develop internal control, thus reducing their need to control by self-starvation. Distraction does not focus on the client's need for control. Doing frequent room checks reinforces feelings of powerlessness and the need to continue with the dysfunctional behavior. Participating in long discussions about food does not make the client want to eat, but rather this strategy allows her to indulge in her preoccupation and to continue with the dysfunctional behavior.