Nokea
The nurse is caring for a client prescribed digoxin. Which manifestations correlate with a digoxin level of 2.3 ng/dL (2.93 nmol/L)? Select all that apply.
- A. Nausea
- B. Drowsiness
- C. Photophobia
- D. Increased appetite
- E. Increased energy level
- F. Seeing halos around bright objects
Correct Answer: A,B,C,F
Rationale: Digoxin is a cardiac glycoside used to manage and treat heart failure, control ventricular rate in clients with atrial fibrillation, and treat and prevent recurrent paroxysmal atrial tachycardia. The therapeutic range is 0.8 to 2.0 ng/mL (1.02 to 2.56 nmol/L). Signs of toxicity include gastrointestinal disturbances, including anorexia, nausea, and vomiting; neurological abnormalities such as fatigue, headache, depression, weakness, drowsiness, confusion, and nightmares; facial pain; personality changes; and ocular disturbances such as photophobia, halos around bright lights, and yellow or green color perception.
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The nurse, caring for a client who has been placed in Buck's extension traction while awaiting surgical repair of a fractured femur, should perform a complete neurovascular assessment of the affected extremity that include which interventions? Select all that apply.
- A. Vital signs
- B. Bilateral lung sounds
- C. Pulse in the affected extremity
- D. Level of pain in the affected leg
- E. Skin color of the affected extremity
- F. Capillary refill of the affected toes
Correct Answer: C,D,E,F
Rationale: A complete neurovascular assessment of an extremity includes color, sensation, movement, capillary refill, and pulse of the affected extremity. Options 1 and 2 are not related to neurovascular assessment.
The nurse creates a discharge plan for a client diagnosed with peripheral neuropathy of the lower extremities. Which instructions should the nurse include in the plan? Select all that apply.
- A. Wear support or elastic stockings.
- B. Wear well-fitted shoes and walk barefoot when at home.
- C. Wear dark-colored stockings or socks and change them daily.
- D. Use a heating pad set at low setting on the feet if they feel cold.
- E. Apply lanolin or lubricating lotion to the legs and feet once or twice daily.
- F. Wash the feet and legs with mild soap and water and rinse and dry them well.
Correct Answer: A,E,F
Rationale: Peripheral neuropathy is any functional or organic disorder of the peripheral nervous system. Clinical manifestations can include muscle weakness, stabbing pain, paresthesia or loss of sensation, impaired reflexes, and autonomic manifestations. Home care instructions include wearing support or elastic stockings for dependent edema, applying lanolin or lubricating lotion to the legs and feet once or twice daily, washing the feet and legs with mild soap and water and rinsing and drying them well, inspecting the legs and feet daily and reporting any skin changes or open areas to the primary health care provider.
A client with an extremity burn injury has undergone a fasciotomy. The nurse prepares to provide which type of wound care to the fasciotomy site?
- A. Dry sterile dressings
- B. Hydrocolloid dressings
- C. Wet, sterile saline dressings
- D. One-half-strength povidone-iodine dressings
Correct Answer: C
Rationale: A fasciotomy is an incision made extending through the subcutaneous tissue and fascia. The fasciotomy site is not sutured but is left open to relieve pressure and edema. The site is covered with wet sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. A hydrocolloid dressing is not indicated for use with clean, open incisions. The incision is clean, not dirty, so there should be no reason to require povidone-iodine. Additionally, povidone-iodine can be irritating to normal tissues.
The nurse admits a client who is bleeding freely from a scalp laceration that resulted from a fall. The nurse should take which action first in the care of this wound?
- A. Prepare for suturing the area.
- B. Determine when the client last had a tetanus vaccine.
- C. Cleanse the wound by flushing with sterile normal saline.
- D. Apply direct pressure to the laceration to stop the bleeding.
Correct Answer: D
Rationale: In the presence of active bleeding from a scalp laceration, the priority is to control the bleeding to prevent further blood loss and stabilize the client. Applying direct pressure to the laceration is the most effective initial action to achieve this. Preparing for suturing, determining tetanus vaccine status, and cleansing the wound are important but secondary actions that follow after bleeding is controlled.
The nurse teaches a postpartum client about postdelivery lochia. The nurse determines that the education has been effective when the client says that on the second day postpartum, the lochia should be which color?
- A. Red
- B. Pink
- C. White
- D. Yellow
Correct Answer: A
Rationale: The uterus rids itself of the debris that remains after birth through a discharge called lochia, which is classified according to its appearance and contents. Lochia rubra is dark red in color. It occurs from delivery to 3 days postpartum and contains epithelial cells, erythrocytes, leukocytes, shreds of decidua, and occasionally fetal meconium, lanugo, and vernix caseosa. Lochia serosa is a brownish pink discharge that occurs from days 4 to 10. Lochia alba is a white discharge that occurs from days 10 to 14. Lochia should not be yellow or contain large clots; if it does, the cause should be investigated without delay.