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The nurse is administering digoxin, a cardiac glycoside, to the client with congestive heart failure. Which interventions should the nurse implement? Select all that apply.
- A. Check the apical heart rate for one (1) full minute.
- B. Monitor the client's serum sodium level.
- C. Teach the client how to take his or her radial pulse.
- D. Evaluate the client's serum digoxin level.
- E. Assess the client for buffalo hump and moon face.
Correct Answer: A,C,D
Rationale: Checking apical HR prevents bradycardia, teaching pulse empowers monitoring, and digoxin levels ensure therapeutic range. Sodium or Cushingoid features are irrelevant.
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A post-operative client has a prescription for acetaminophen with codeine. What should the nurse recognize as a primary effect of this combination?
- A. Enhanced pain relief
- B. Minimized side effects
- C. Prevention of drug tolerance
- D. Increased onset of action
Correct Answer: A
Rationale: Enhanced pain relief. Combination of analgesics with different mechanisms of action can afford greater pain relief.
An adult is receiving gentamicin IV q8h. Which laboratory tests does the nurse expect that the client will have done regularly?
- A. CBC and hemoglobin
- B. BUN and serum creatinine
- C. SGOT and SGPT
- D. Urine and blood cultures
Correct Answer: B
Rationale: BUN and serum creatinine are tests of renal function. Gentamicin is nephrotoxic. All persons receiving gentamicin should have these tests done regularly to assess for toxicity.
The male client is self-medicating with the H-2 antagonist cimetidine (Tagamet). Which complication can occur while taking this medication?
- A. Melena.
- B. Gynecomastia.
- C. Pyrosis.
- D. Eructation.
Correct Answer: B
Rationale: Cimetidine can cause gynecomastia due to antiandrogen effects, especially in males. Melena, pyrosis, or eructation are unrelated.
The health care provider has written 'Morphine sulfate 2 mgs IV every 3-4 hours prn for pain' on the chart of a child weighing 22 lb. (10 kg). What is the nurse's initial action?
- A. Check with the pharmacist
- B. Hold the medication and contact the provider
- C. Administer the prescribed dose as ordered
- D. Give the dose every 6-8 hours
Correct Answer: B
Rationale: Hold the medication and contact the provider. The usual pediatric dose of morphine is 0.1 mg/kg every 3 to 4 hours. At 10 kg, this child typically should receive 1.0 mg every 3 to 4 hours.
A client with an aplastic sickle cell crisis is receiving a blood transfusion and begins to complain of 'feeling hot.' Almost immediately, the client begins to wheeze. What is the nurse's first action?
- A. Stop the blood infusion
- B. Notify the health care provider
- C. Take/record vital signs
- D. Send blood samples to lab
Correct Answer: A
Rationale: Stop the blood infusion. If a reaction of any type is suspected during administration of blood products, stop the infusion immediately, keep the line open with saline, notify the health care provider, monitor vital signs and other changes, and then send a blood sample to the lab.