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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A client diagnosed with pneumonia reports a decreased sense of taste that has greatly affected the motivation to eat and drink. Which intervention should the nurse implement to help increase the client's appetite?
- A. Offer in-between meal snacks.
- B. Provide three large meals daily.
- C. Provide mouth care before meals.
- D. Offer to sit with the client during meals.
Correct Answer: C
Rationale: The client with pneumonia may experience decreased taste sensation as a result of sputum expectoration. To minimize this adverse effect, the nurse should provide oral hygiene before meals. The client should also have small, frequent meals because of dyspnea. The remaining options will not address the issue of impaired sense of taste.
A client with a known history of panic disorder comes to the emergency department and states to the nurse, 'Please help me. I think I'm having a heart attack.' What is the priority nursing action?
- A. Assess the client's vital signs.
- B. Encourage the client to use relaxation techniques.
- C. Identify the manifestations related to the panic disorder.
- D. Determine what the client's activity involved when the pain started.
Correct Answer: A
Rationale: Clients with a panic disorder can experience acute physical symptoms, such as chest pain and palpitations. The priority is to assess the client's physical condition to rule out a physiological disorder for these signs and symptoms. Although options 2, 3, and 4 may be appropriate at some point in the care of the client, they are not the priority.
When tranylcypromine is prescribed for a client, which food items should the nurse instruct the client to avoid? Select all that apply.
- A. Figs
- B. Apples
- C. Bananas
- D. Broccoli
- E. Sauerkraut
- F. Baked chicken
Correct Answer: A,C,E
Rationale: Tranylcypromine is a monoamine oxidase inhibitor (MAOI) used to treat depression. Foods that contain tyramine need to be avoided because of the risk of hypertensive crisis associated with use of this medication. Foods to avoid include figs; bananas; sauerkraut; avocados; soybeans; meats or fish that are fermented, smoked, or otherwise aged; some cheeses; yeast extract; and some beers and wine.
The nurse teaching an older client about general hygienic measures for foot and nail care should include which instructions? Select all that apply.
- A. Wear knee-high hose to prevent edema.
- B. Soak and wash the feet daily using cool water.
- C. Use commercial removers for corns or calluses.
- D. Use over-the-counter preparations to treat ingrown nails.
- E. Apply lanolin or baby oil if dryness is noted along the feet.
- F. Pat the feet dry thoroughly after washing and dry well between toes.
Correct Answer: E,F
Rationale: The nurse should offer the following guidelines in a general hygienic foot and nail care program: Inspect the feet daily, including the tops and soles of the feet, the heels, and the areas between the toes; wash the feet daily using lukewarm water, and avoid soaks to the feet, thoroughly patting the feet dry and drying well between toes; and avoid cutting corns or calluses or using commercial removers. Additional general hygienic measures include gently rubbing lanolin, baby oil, or corn oil into the skin if dryness is noted along the feet or between the toes; filing the toe nails straight across and square (do not use scissors or clippers); avoiding the use of over-the-counter preparations to treat ingrown toenails and consulting a primary health care provider for these problems; and avoiding wearing elastic stockings (unless prescribed by a health care professional), knee-high hose, or constricting garters.
The nurse inserts an indwelling Foley catheter into the bladder of a postoperative client who has not voided for 8 hours and has a distended bladder. After the tubing is secured and the collection bag is hung on the bed frame, the nurse notices that 900 mL of urine has drained into the collection bag. What is the appropriate nursing action for the safety of this client?
- A. Check the specific gravity of the urine.
- B. Clamp the tubing for 30 minutes and then release.
- C. Provide suprapubic pressure to maintain a steady flow of urine.
- D. Raise the collection bag high enough to slow the rate of drainage.
Correct Answer: B
Rationale: Rapid emptying of a large volume of urine may cause engorgement of pelvic blood vessels and hypovolemic shock, prolapse of the bladder, or bladder spasms. Clamping the tubing for 30 minutes allows for equilibration to prevent complications. Option 1 is an assessment and would not affect the flow of urine or prevent possible hypovolemic shock. Option 3 would increase the flow of urine, which could lead to hypovolemic shock. Option 4 could cause backflow of urine. Infection is likely to develop if urine is allowed to flow back into the bladder.