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The healthcare professional is caring for a client with heart failure who is receiving digoxin (Lanoxin). Which assessment finding requires immediate intervention?
- A. Heart rate of 58 beats per minute.
- B. Nausea and vomiting.
- C. Blood pressure of 130/80 mm Hg.
- D. Shortness of breath.
Correct Answer: B
Rationale: The correct answer is B: Nausea and vomiting. This finding requires immediate intervention because digoxin toxicity can present with gastrointestinal symptoms like nausea and vomiting. This can indicate an overdose of digoxin, which can be life-threatening. Prompt action is necessary to prevent further complications.
A: Heart rate of 58 beats per minute is within the therapeutic range for digoxin and does not require immediate intervention.
C: Blood pressure of 130/80 mm Hg is also within normal limits and does not indicate an urgent issue.
D: Shortness of breath can be a symptom of heart failure but is not a direct indication of digoxin toxicity requiring immediate intervention.
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The patient has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?
- A. Maintain the patient on bed rest.
- B. Auscultate lung sounds every 4 hours.
- C. Monitor for Trousseau's and Chvostek's signs.
- D. Encourage fluid intake up to 4000 mL every day.
Correct Answer: D
Rationale: The correct answer is D: Encourage fluid intake up to 4000 mL every day. High calcium levels can lead to dehydration, so encouraging fluid intake helps prevent this complication. Increased fluid intake also promotes calcium excretion through urine. Bed rest (A) is not directly related to managing high calcium levels. Auscultating lung sounds (B) every 4 hours is more relevant for respiratory issues. Monitoring for Trousseau's and Chvostek's signs (C) is associated with low calcium levels, not high levels.
What skin care instructions should the nurse give to a patient receiving external beam radiation therapy for cancer treatment?
- A. Use a heating pad to relieve any pain in the treated area.
- B. Apply alcohol-based lotions to the treated area daily.
- C. Avoid exposing the treated area to sunlight.
- D. Wash the treated area with hot water and strong soap.
Correct Answer: C
Rationale: The correct answer is C: Avoid exposing the treated area to sunlight. This is important because radiation therapy can make the skin more sensitive to sunlight, leading to increased risk of sunburn and skin damage. Sun exposure can worsen skin reactions and delay healing. Choice A is incorrect because heat sources like heating pads can exacerbate skin irritation. Choice B is incorrect as alcohol-based lotions can further irritate the skin. Choice D is incorrect as hot water and strong soap can be too harsh on the sensitive skin. Overall, protecting the treated area from sunlight is crucial for optimal skin care during radiation therapy.
A patient with a diagnosis of peptic ulcer disease is prescribed omeprazole. When should the patient take this medication for optimal effectiveness?
- A. With meals
- B. At bedtime
- C. Before meals
- D. After meals
Correct Answer: C
Rationale: The correct answer is C: Before meals. Omeprazole is a proton pump inhibitor that works by reducing stomach acid production. Taking it before meals allows the medication to be most effective in inhibiting the proton pumps before they are stimulated by food intake. This timing optimizes the drug's ability to reduce acid secretion during the digestion process.
Choice A (With meals) is incorrect because taking omeprazole with meals may reduce its effectiveness as it will not have enough time to inhibit acid production before food intake. Choice B (At bedtime) is also incorrect as omeprazole works best when taken before meals to prevent acid production. Choice D (After meals) is incorrect because waiting until after meals to take omeprazole means that acid production has already been stimulated by the food consumed, reducing the drug's effectiveness in inhibiting acid secretion.
A patient with chronic obstructive pulmonary disease (COPD) is experiencing severe dyspnea. What position should the nurse encourage the patient to assume?
- A. Supine
- B. Prone
- C. High Fowler's
- D. Trendelenburg
Correct Answer: C
Rationale: The correct answer is C: High Fowler's. This position helps improve lung expansion and breathing efficiency by maximizing chest expansion. Sitting upright reduces pressure on the diaphragm, allowing for better ventilation. Supine (A) position can worsen dyspnea by restricting lung expansion. Prone (B) position is not ideal for COPD patients as it can hinder breathing. Trendelenburg (D) position, where the patient's feet are elevated above the head, can increase pressure on the diaphragm and impair breathing, making it inappropriate for a patient experiencing severe dyspnea.
A client with liver cirrhosis is being educated about managing their condition. Which statement by the client indicates a need for further teaching?
- A. I will avoid drinking alcohol
- B. I need to limit my salt intake
- C. I can take acetaminophen for pain
- D. I should eat a balanced diet
Correct Answer: C
Rationale: The correct answer is C: "I can take acetaminophen for pain." Acetaminophen can be harmful to the liver, especially in individuals with liver cirrhosis. The liver is responsible for metabolizing acetaminophen, and in cirrhosis, its function is impaired, leading to potential toxicity. Choice A is correct as alcohol can worsen liver damage. Choice B is correct as excess salt can lead to fluid retention and complications. Choice D is correct as a balanced diet is important for overall health. Therefore, the statement about taking acetaminophen indicates a need for further teaching.