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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 nurse is reviewing a nutritional plan for a 6-month-old who has recently been started on solid foods. Which of the following recommendations has the highest priority in the plan?
- A. Canned baby food is more expensive than food prepared at home
- B. Finger foods can be introduced before the child has teeth
- C. New foods should be introduced at least 5-7 days apart
- D. Rice cereal can be mixed with cow's milk to increase nutritional intake
Correct Answer: C
Rationale: Introducing new foods 5-7 days apart (C) prevents allergic reactions by identifying triggers, making it the priority. Cost (A), finger foods (B), and cow's milk (D, not recommended before 12 months) are secondary.
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.
The nurse is assessing a client at 11 weeks gestation. The first day of the client's last menstrual period was September 7. Which of the following findings should the nurse expect to obtain?
- A. reports feeling fetal movement
- B. reports increased urinary frequency
- C. fundal height of 24 cm above the symphysis pubis
- D. estimated delivery date of June 14 using the Naegele rule
- E. fetal heart tones detectable via Doppler ultrasound device
Correct Answer: B,D,E
Rationale: At 11 weeks, increased urinary frequency (B) is expected due to hormonal changes. The Naegele rule (LMP + 1 year - 3 months + 7 days) gives June 14 (D). Fetal heart tones are detectable by Doppler (E). Fetal movement (A) is felt later (16-20 weeks), and fundal height of 24 cm (C) occurs around 24 weeks.
A charge nurse suspects that the unlicensed assistive personnel (UAP) is falsifying the documentation of clients' capillary glucose results rather than performing the test. What is the best action by the charge nurse to handle this situation?
- A. Ask a client if the UAP has performed the test
- B. Discuss the importance of task completion and accurate documentation in a staff meeting
- C. Give the UAP a verbal warning not to falsify data
- D. Take a client's capillary glucose personally and compare it to the recorded result
Correct Answer: D
Rationale: Verifying the glucose result personally (D) provides evidence of falsification. Asking a client (A) is unreliable, a staff meeting (B) is too general, and a warning (C) is premature without proof.
The nurse has taught the parent of a pediatric client who will be receiving growth hormone replacement therapy. Which of the following statements by the parent would require follow-up?
- A. The medication needs to be given at bedtime to be most effective.
- B. My child will achieve a height equal to peers after receiving therapy.
- C. The medication will be discontinued when my child's bone growth ceases.
- D. Routine x-rays may be required during therapy to monitor bone lengthening.
Correct Answer: B
Rationale: Expecting equal height to peers (B) is unrealistic, as outcomes vary. Bedtime dosing (A), discontinuation at bone closure (C), and x-rays (D) are correct.