Nokea
The nurse is caring for a client with a history of heart failure who is receiving digoxin 0.125 mg PO daily. Which of the following symptoms should the nurse report immediately?
- A. Fatigue and weakness.
- B. Nausea and loss of appetite.
- C. Occasional palpitations.
- D. Mild ankle edema.
Correct Answer: B
Rationale: Nausea and loss of appetite suggest digoxin toxicity, a medical emergency. Options A, C, and D are less specific or expected in heart failure.
You may also like to solve these questions
The physician suggests play therapy for a 7-year-old girl who is having some difficulty adjusting to her parents' impending divorce. The nurse knows this type of therapy is useful because
- A. young children have difficulty verbalizing emotions.
- B. children hesitate to confide in anyone but their parents.
- C. play is an enjoyable form of therapy for children.
- D. play therapy is helpful in preventing regression.
Correct Answer: A
Rationale: children have difficulty putting feelings into words; play is how they express themselves
The nurse observes that a child with muscular dystrophy has a positive Gower's sign. The nurse documents that the child:
- A. Has weak deep tendon reflexes
- B. Must use his hands to rise from the floor
- C. Has increased spinal reflexes
- D. Rocks back and forth in rhythmical fashion
Correct Answer: B
Rationale: A positive Gower's sign indicates the child uses their hands to push up from the floor due to muscle weakness, so B is correct. Answers A, C, and D do not describe Gower's sign.
The school nurse conducts a class on childcare at the local high school. During the class, one of the participants asks the nurse what age is best to start toilet training a child. Which of the following is the BEST response by the nurse?
- A. 11 months of age.
- B. 14 months of age.
- C. 17 months of age.
- D. 20 months of age.
Correct Answer: D
Rationale: by 24 months may be able to achieve daytime bladder control
The nurse is teaching a client with a new diagnosis of osteoarthritis about celecoxib (Celebrex). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice
- B. Report any black, tarry stools
- C. Stop the medication if pain decreases
- D. Avoid regular joint exams
Correct Answer: B
Rationale: Black, tarry stools indicate gastroinTest inal bleeding, a serious celecoxib side effect. Options A, C, and D are incorrect: grapefruit juice is irrelevant, stopping the medication may not be advised, and exams are needed.
The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing the flatus from a 1 piece drainable ostomy pouch. Which is the correct intervention?
- A. Piercing the plastic of the ostomy pouch with a pin to vent the flatus
- B. Opening the bottom of the pouch, allowing the flatus to be expelled
- C. Pulling the adhesive seal around the ostomy pouch to allow the flatus to escape
- D. Assisting the client to ambulate to reduce the flatus in the pouch
Correct Answer: B
Rationale: Opening the bottom of the pouch, allowing the flatus to be expelled, is the correct way to vent a 1-piece drainable ostomy pouch.