Nokea
The home health nurse is reinforcing teaching for a client with atrial fibrillation who is prescribed digoxin 0.25 mg orally on even-numbered days. Which client statement will require further teaching about digoxin?
- A. I will call the health care provider if I don't feel like eating.
- B. I will call the health care provider if I feel dizzy and lightheaded.
- C. I will call the health care provider if I have trouble reading.
- D. I will take my blood pressure before taking my medicine.
Correct Answer: D
Rationale: Taking blood pressure (D) is unrelated to digoxin monitoring. Anorexia (A Anorexia (A), dizziness (B), and visual changes (C) are signs of digoxin toxicity, requiring provider notification.
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The charge nurse observes a student nurse administering a tuberculin skin test using the intradermal route. Which action by the student nurse requires intervention and additional teaching from the charge nurse?
- A. Advances tip of needle through epidermis until the bevel is no longer visible under the skin
- B. Chooses a 1-mL tuberculin syringe with a 27-gauge, 1/4-inch needle; dons clean gloves
- C. Injects medication slowly while raising a small wheal (bleb) on the skin
- D. Inserts needle at a 10-degree angle almost parallel to the skin with the bevel up
Correct Answer: A
Rationale: Advancing until the bevel is invisible (A) is too deep for intradermal injection, requiring intervention. Syringe choice (B), wheal formation (C), and angle (D) are correct.
The physician has ordered dressings with sulfamylon cream for a client with full thickness burns of his hands and arms. Before dressing changes, the nurse should give priority to:
- A. Administering pain medication
- B. Checking the adequacy of urinary output
- C. Requesting a daily complete blood count
- D. Obtaining a blood glucose by finger stick
Correct Answer: A
Rationale: Sulfamylon dressing changes are painful, so administering pain medication is the priority. Urinary output , blood count , and glucose are important but secondary.
The nurse is observing a staff member collecting a sputum specimen from a client with active tuberculosis. The nurse should intervene if the staff member is observed
- A. leaving unused supplies in the client's room after the procedure
- B. putting on clean gloves before putting on a protective gown
- C. leaving a dedicated, disposable stethoscope in the client's room
- D. putting on an N95 respirator mask and face shield before entering the client's room
Correct Answer: A
Rationale: Leaving supplies (A) in a TB room risks contamination. Gloves before gown (B), dedicated stethoscope (C), and N95 with face shield (D) are appropriate.
Which of these clients, all of whom have the findings of a board-like abdomen, would the nurse suggest that the provider examine first?
- A. An elderly client who stated, 'My awful pain in my right side suddenly stopped about 3 hours ago.'
- B. A pregnant woman of 8 weeks newly diagnosed with an ectopic pregnancy
- C. A middle-aged client admitted with diverticulitis who has taken only clear liquids for the past week
- D. A teenager with a history of falling off a bicycle without hitting the handle bars
Correct Answer: A
Rationale: An elderly client who stated, 'My awful pain in my right side suddenly stopped about 3 hours ago.' This client has the highest risk for hypovolemic and septic shock since the appendix has most likely ruptured, based on the history of the pain suddenly stopping over three hours ago. Elderly clients have less functional reserve for the body to cope with shock and infection over long periods. The others are at risk for shock also, however given that they fall in younger age groups, they would more likely be able to tolerate an imbalance in circulation. A common complication of falling off a bicycle is hitting the handle bars in the upper abdomen often on the left, resulting in a ruptured spleen.
The nurse has performed the initial assessments of 4 clients admitted with an acute episode of asthma. Which assessment finding would cause the nurse to call the provider immediately?
- A. prolonged inspiration with each breath
- B. expiratory wheezes that are suddenly absent in 1 lobe
- C. expectoration of large amounts of purulent mucous
- D. appearance of the use of abdominal muscles for breathing
Correct Answer: B
Rationale: Acute asthma is characterized by expiratory wheezes caused by obstruction of the airways. Sudden cessation of wheezing is an ominous sign that indicates an emergency -- the small airways are now collapsed.