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The nurse is caring for a client prescribed digoxin to help manage heart failure. Which manifestations correlate with a digoxin level of 2.3 ng/dL? (Select all that apply.)
- A. Increased appetite.
- B. Nausea.
- C. Increased energy level.
- D. Seeing halos around bright objects.
- E. Photophobia.
Correct Answer: B,D,E
Rationale: The correct manifestations correlating with a digoxin level of 2.3 ng/dL are Nausea, Seeing halos around bright objects, and Photophobia. Nausea is a common side effect of digoxin toxicity. Seeing halos around bright objects is a sign of visual disturbances associated with digoxin toxicity. Photophobia is sensitivity to light, which can occur with digoxin toxicity. Increased appetite and energy levels are not typically associated with digoxin toxicity and are therefore incorrect choices.
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A nurse is caring for a client. Select the 5 findings that can cause delayed wound healing.
- A. Potassium level.
- B. Prealbumin level.
- C. History of diabetes mellitus.
- D. History of hyperlipidemia.
- E. Wound infection.
- F. Decreased pedal perfusion.
- G. Fasting blood glucose.
Correct Answer: B,C,E,F,G
Rationale: The correct answer choices (B, C, E, F, G) can cause delayed wound healing due to specific reasons.
B: Prealbumin level reflects protein status, crucial for wound healing.
C: Diabetes mellitus impairs circulation and immune response, affecting healing.
E: Wound infection introduces pathogens, prolonging inflammation and delaying healing.
F: Decreased pedal perfusion reduces oxygen and nutrient delivery to the wound site.
G: Elevated fasting blood glucose hinders immune cell function and collagen synthesis.
Incorrect choices (A, D) are not directly linked to wound healing delays. Potassium level (A) mainly affects cardiac and muscle function, and hyperlipidemia (D) primarily impacts cardiovascular health, not wound healing directly.
A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse plan to implement?
- A. Vitamin B supplements.
- B. Iron supplements.
- C. Vitamin B12 injections.
- D. Blood transfusions.
Correct Answer: C
Rationale: The correct answer is C: Vitamin B12 injections. Pernicious anemia is caused by a lack of intrinsic factor necessary for Vitamin B12 absorption. Vitamin B12 injections bypass the need for intrinsic factor, ensuring the client receives an adequate amount of the vitamin. Iron supplements (B) are not effective in treating pernicious anemia as it is not related to iron deficiency. Vitamin B supplements (A) may not be absorbed effectively due to the lack of intrinsic factor. Blood transfusions (D) may be used for severe cases of anemia, but they do not address the underlying Vitamin B12 deficiency in pernicious anemia.
A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect?
- A. Unilateral joint involvement.
- B. Ulnar deviation.
- C. Decreased sedimentation rate.
- D. Fractures of the spine.
Correct Answer: B
Rationale: The correct answer is B: Ulnar deviation. In rheumatoid arthritis, ulnar deviation of the fingers is a common finding due to inflammation and destruction of the joints. This deformity leads to the fingers deviating towards the ulnar side of the hand. This is a characteristic feature seen in rheumatoid arthritis and is caused by the inflammation affecting the joints. Choices A, C, and D are incorrect. A: Unilateral joint involvement is not typical of rheumatoid arthritis, as it usually affects multiple joints symmetrically. C: Decreased sedimentation rate is not expected in rheumatoid arthritis, as it is typically associated with an elevated sedimentation rate due to inflammation. D: Fractures of the spine are not a common finding in rheumatoid arthritis, as it primarily affects the joints.
A client seeks medical attention for intermittent signs and symptoms that suggest a diagnosis of Raynaud’s disease. The nurse should assess the trigger of these signs/symptoms by asking which?
- A. Does drinking coffee or ingesting chocolate seem related to the episodes?
- B. Does being exposed to heat seem to cause the episodes?
- C. Do the signs and symptoms occur while you are asleep?
- D. Have you experienced any injuries that have limited your activity levels lately?
Correct Answer: A
Rationale: The correct answer is A: Does drinking coffee or ingesting chocolate seem related to the episodes? This question is relevant because caffeine and chocolate are known triggers for Raynaud's disease due to their vasoconstrictive properties. By asking about these specific triggers, the nurse can gather important information to help identify potential causes of the client's symptoms.
Choice B is incorrect because exposure to heat typically alleviates symptoms of Raynaud's disease rather than causing them. Choice C is irrelevant as Raynaud's symptoms typically occur when the individual is exposed to cold or experiencing stress, not while asleep. Choice D is also incorrect as injuries limiting activity levels are not directly related to Raynaud's disease triggers.
A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?
- A. The area surrounding the insertion site feels warm to the touch.
- B. The infusion rate has stopped but the tubing is not kinked.
- C. There is fluid leaking around the insertion site.
- D. There is no blood return when the tubing is aspirated.
Correct Answer: A
Rationale: The correct answer is A because warmth at the insertion site is a classic sign of phlebitis, indicating inflammation of the vein. This is due to irritation from the IV catheter. Choice B is incorrect because the infusion rate stopping is not specific to phlebitis. Choice C is incorrect as fluid leaking suggests an issue with the dressing or the catheter. Choice D is incorrect as no blood return could indicate a clot but not necessarily phlebitis.