Nokea
The nurse is caring for an adult who is taking digoxin (Lanoxin) 0.25 mg daily. Which comment by the client is of greatest concern to the nurse because the client is taking digoxin?
- A. I don't seem to have much of an appetite lately.'
- B. My energy level is not as high as it once was.'
- C. My pulse yesterday was 60.'
- D. I have a pain in my right foot.'
Correct Answer: C
Rationale: A pulse of 60 may indicate bradycardia, a potential sign of digoxin toxicity, requiring immediate assessment. Anorexia and fatigue are less specific, and foot pain is unrelated to digoxin.
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The nurse is caring for a client with a chest tube. On the second postoperative day, the chest tube accidentally disconnects from the drainage tube. The first action the nurse should take is
- A. reconnect the tube
- B. raise the collection chamber above the client's chest
- C. call the health care provider
- D. clamp the chest tube
Correct Answer: D
Rationale: Immediate steps should be taken to prevent air from entering the chest cavity. Lung collapse may occur if air enters the chest cavity. Clamping the tube close to the client's chest is the first action to take, followed by health care provider notification.
An elderly client with glaucoma is scheduled for an exploratory laparotomy. Which of the following pre-op medications should be questioned?
- A. Demerol (meperidine)
- B. Atropine (atropine)
- C. Tagamet (cimetadine)
- D. Polycillin (ampicillin)
Correct Answer: B
Rationale: Atropine is contraindicated in glaucoma as it can increase intraocular pressure. Demerol , Tagamet , and Polycillin are generally safe in this context.
The nurse is caring for an older adult. Which statement made by the client is not typical of normal aging?
- A. I seem to be more sensitive to the taste of salt than I used to be.'
- B. I have trouble reading the newspaper.'
- C. I don't drive at dusk anymore.'
- D. Sometimes I have trouble matching my socks.'
Correct Answer: A
Rationale: Increased sensitivity to salt taste is not typical of aging; taste sensitivity usually decreases. Difficulty reading, avoiding dusk driving, and color matching issues are normal aging changes.
Hospital staff requests that the parents with a Greek heritage of a hospitalized infant remove the amulet from around the child's neck. The parents refuse. The nurse understands that the parents may be concerned about
- A. Mental development delays
- B. Evil eye or envy of others
- C. Fright from spiritual beings
- D. Balance in body systems
Correct Answer: B
Rationale: Evil eye or envy of others. In Greek culture, amulets protect against 'matiasma' or the evil eye, especially for children.
The nurse is caring for a man who has chronic emphysema and is receiving oxygen at 2 L/min. The nurse enters the room to find that his wife has turned the oxygen up to 10 L/min because her husband is having increasing difficulty breathing. What is the best immediate action for the nurse to take?
- A. Explain to the wife that his oxygen was ordered at 2 L/min and it should stay there until the physician orders something else
- B. Turn the oxygen setting back to 2 L/min
- C. Tell the wife that 10 L/min is too high and turn it back to 5 L/min
- D. Assure her that 10 L/min will ease her husband's breathing
Correct Answer: B
Rationale: High oxygen in emphysema can suppress respiratory drive, worsening hypercapnia; returning to 2 L/min is critical, followed by physician consultation.