Nokea
The nurse finds that a client receiving digoxin (Lanoxin) 0.25 mg orally has an apical pulse of 54. Which of the following should the nurse do first?
- A. withhold the medicine and contact the prescribing physician
- B. ask another nurse to verify the apical pulse
- C. administer the medication and recheck the pulse in 30 minutes
- D. order a stat ECG
Correct Answer: A
Rationale: An apical pulse of 54 is below the safe threshold (typically 60) for digoxin, indicating potential toxicity. Withholding the dose and notifying the provider is the priority.
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The nurse is caring for a client with a wound with purulent, foul-smelling drainage. A wound culture is ordered. Which describes the correct collection technique?
- A. clean the wound with normal saline before obtaining specimen
- B. allow 24 hours for antibiotic therapy to take effect before sampling
- C. obtain the specimen from the drainage at the bottom of the wound
- D. culture the outer surface around the wound before collecting exudate
Correct Answer: A
Rationale: Cleaning the wound with saline removes surface contaminants, ensuring an accurate culture from viable tissue.
The nurse is reviewing a client's PRN pain medications. There is an order for acetaminophen 1,000 mg PO q4 hours as needed for pain. How should the nurse proceed?
- A. call the health care provider to clarify the order
- B. administer the medication as ordered if needed for pain
- C. give other PRN medications for pain and ignore the order
- D. avoid giving pain medication every 4 hours and give it every 6 hours
Correct Answer: B
Rationale: Acetaminophen 1,000 mg q4 hours PRN is within safe dosing (max 4,000 mg/day), so it can be administered as ordered.
The child with seizure disorder is being treated with phenytoin (Dilantin). Which of the following statements by the patient's mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy?
- A. She is very irritable lately.
- B. She sleeps quite a bit of the time.
- C. Her gums look too big for her teeth.
- D. She has gained about 10 pounds in the last six months.
Correct Answer: C
Rationale: Gingival hyperplasia is a common side effect of phenytoin therapy.
A newly admitted client has sickle cell crisis. He is complaining of pain in his feet and hands. The nurse's assessment findings include a pulse oximetry of 92. Assuming that all the following interventions are ordered, which should be done first?
- A. Adjust the room temperature
- B. Give a bolus of IV fluids
- C. Start O2
- D. Administer meperidine (Demerol) 75 mg IV push
Correct Answer: C
Rationale: A pulse oximetry of 92 indicates hypoxemia, so administering oxygen is the priority to improve oxygenation and prevent further sickling.
A nurse is at a local swimming pool, and a man collapses with a cardiac arrest after exiting the pool. The man is still wet when the nurse begins cardiopulmonary resuscitation (CPR), and another person brings the automated external defibrillator (AED). Which of the following should the nurse do next?
- A. Apply the AED pads and deliver a shock.
- B. Wipe the chest dry with an available cloth or towel.
- C. Continue CPR because a client who is wet cannot receive a shock.
- D. Wipe the chest with an alcohol hand wipe to speed the evaporation of the water.
Correct Answer: B
Rationale: Wiping the chest dry (B) ensures AED pads adhere properly and deliver an effective shock. Applying pads on a wet chest (A) risks ineffective defibrillation, continuing CPR (C) delays defibrillation, and alcohol wipes (D) are inappropriate.