Nokea
The client is prescribed digoxin (Lanoxin) for heart failure. Which instruction should the nurse include in the teaching plan?
- A. Take the medication with meals to prevent nausea.'
- B. Report a pulse below 60 beats per minute.'
- C. Increase potassium-rich foods in your diet.'
- D. Take an extra dose if you miss one.'
Correct Answer: B
Rationale: Digoxin toxicity is increased with bradycardia, so a pulse below 60 beats per minute should be reported. It can be taken with or without food, potassium monitoring is important but not increasing, and extra doses are dangerous.
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The nurse is caring for a client with a diagnosis of gestational hypertension. Which complication is most likely to occur?
- A. Preeclampsia
- B. Preterm labor
- C. Fetal macrosomia
- D. All of the above
Correct Answer: A
Rationale: Gestational hypertension can progress to preeclampsia characterized by proteinuria and other systemic symptoms and is the most likely complication. Preterm labor and macrosomia are less directly related.
The most appropriate method of evaluating whether the diet of a child with cystic fibrosis is meeting his caloric needs is:
- A. Careful monitoring of weight loss or gain
- B. Carefully recording amounts and types of foods ingested
- C. Keeping a strict account of the number of calories ingested
- D. Keeping a careful account of the amount of pancreatic enzymes ingested
Correct Answer: A
Rationale: Consistent weight gain, even if it is slow, is an indication that the child is eating and digesting sufficient calories.
Which nursing implication is appropriate for a client undergoing a paracentesis?
- A. Have the client void before the procedure.
- B. Keep the client NPO.
- C. Observe the client for hypertension following the procedure.
- D. Place the client on the right side following the procedure.
Correct Answer: A
Rationale: A full bladder impedes ascitic fluid withdrawal during paracentesis, so the client should void beforehand.
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.
An obstetrical client is admitted in active labor. During examination,the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
- A. Document the finding
- B. Report the finding to the physician
- C. Prepare the client for a C-section
- D. Continue primary care as prescribed
Correct Answer: B
Rationale: A papular lesion on the perineum during labor could indicate an infectious condition (e.g. herpes simplex virus) which poses risks to the newborn. Reporting to the physician is the most appropriate initial action to determine management such as the need for a C-section.