Nokea
The nurse is caring for a client with a history of heart failure who is receiving digoxin (Lanoxin) 0.25 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel tired in the afternoon.
- B. I have nausea and no appetite.
- C. I have a headache sometimes.
- D. I take my medication with food.
Correct Answer: B
Rationale: Nausea and loss of appetite are signs of digoxin toxicity, a serious complication requiring immediate evaluation, especially in heart failure. Options A, C, and D are less concerning: fatigue and headaches are nonspecific, and taking digoxin with food is acceptable.
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A ten-year-old child with leukemia has a large burn on her arm and the burn appears to be oily. The client states that she touched a hot pan, and her mother put cooking fat on it so it would not blister.
The nurse should
- A. document the findings in the chart.
- B. call the physician immediately to report the injury.
- C. teach the client that oil holds germs and makes infection more likely.
- D. wash the burn with soap and water to remove the oil.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not address the immediate problem of cleansing the wound (2) unnecessary (3) does not address the immediate problem of cleansing the wound (4) correct-because leukemic clients are immunosuppressed, they are more susceptible to infections; cooking fat applied to an open wound increases the possibility of infection; burns should be rinsed immediately with tap water to reduce the heat in the burn
The nurse is caring for a client with a history of cirrhosis who is receiving lactulose (Chronulac) 30 mL PO tid. Which of the following findings should the nurse report immediately?
- A. Ammonia level of 40 mcg/dL.
- B. Potassium 3.5 mEq/L.
- C. Diarrhea with 4 stools per day.
- D. Sodium 140 mEq/L.
Correct Answer: C
Rationale: Diarrhea with 4 stools per day suggests lactulose overdose, risking dehydration. Options A, B, and D are normal.
The doctor has ordered chlorpromazine (Thorazine) to control an alcoholic client's restlessness, agitation, and irritability following surgery. The nurse should check the order with the doctor based on which of the following rationales?
- A. The nurse believes that the client's symptoms reflect alcohol withdrawal.
- B. The nurse does not know if the client is allergic to this medication.
- C. The nurse knows that the client is not psychotic.
- D. The nurse routinely checks on the doctor's orders.
Correct Answer: A
Rationale: medication is contraindicated for the treatment of alcohol withdrawal symptoms; medication will lower client's seizure threshold and BP, causing potentially serious medical consequences
The nurse knows that which psychosocial stage should be a priority to consider while planning care for a 20-year-old client?
- A. Identity versus identity diffusion.
- B. Intimacy versus isolation.
- C. Integrity versus despair and disgust.
- D. Industry versus inferiority.
Correct Answer: B
Rationale: is the stage for 19- to 35-year-olds
After abdominal surgery, a client is admitted from the recovery room with intravenous fluid infusing at 100 cc/h. One hour later, the nurse finds the clamp wide open and notes that the client has received 850 cc.
The nurse would be MOST concerned by which of the following?
- A. A CVP reading of 12 and bradycardia.
- B. Tachycardia and hypotension.
- C. Dyspnea and oliguria.
- D. Rales and tachycardia.
Correct Answer: D
Rationale: Strategy: 'MOST concerned' indicates a complication. (1) CVP is normal, and bradycardia is incorrect (2) does not contain information relevant to fluid overload (3) does not contain information relevant to fluid overload (4) correct-indicate cardiovascular fluid overload