Nokea
The nurse is collecting data on a client who is taking prescribed digoxin and furosemide. Which finding requires follow-up?
- A. Night sweats and headache
- B. Vomiting and halos around lights
- C. Fatigue and dry, flaky skin
- D. Low blood pressure and dark urine
Correct Answer: B
Rationale: Vomiting and halos around lights are signs of digoxin toxicity, requiring immediate follow-up.
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The following scenario applies to the next 1 items
The nurse is caring for a client in active labor
Item 1 of 1
Nurses’ Note
23-year-old primipara at 39 gestational weeks was admitted for induction via oxytocin. Currently, she is 100% effaced and 10 cm dilated. An internal fetal spiral electrode and intrauterine pressure catheter were placed. Uterine contractions are now 2 to 2.5 minutes apart, 70 to 90 seconds in duration. The fetal heart tracing showed decreased fetal heart rate following uterine contraction. This pattern was present in more than 50% of the uterine contractions.
Medications
Oxytocin via continuous infusion
Complete the following sentence from the list of options. Based on the fetal heart rate tracing, the client is experiencing ___ that is caused by ___
- A. late decelerations
- B. early decelerations
- C. variable decelerations
- D. reduced blood flow to the placenta
- E. umbilical cord compression
- F. fetal head compression
Correct Answer: A, D
Rationale: Late decelerations, caused by reduced placental blood flow, indicate fetal hypoxia and require intervention.
The nurse is teaching a client with hypertension about dietary modifications. Which of the following statements by the client would require follow-up?
- A. I'm glad I can still eat beef and pork daily.
- B. I will need to get used to eating fruits and vegetables.
- C. I should avoid eating canned foods.
- D. I already told my spouse to buy me some yogurt when I get home.
Correct Answer: A
Rationale: Daily consumption of red meats like beef and pork is not recommended for hypertension due to high sodium and fat content.
The nurse is caring for a 2-hour-old infant at risk for cold stress. Which of the following assessment findings would support an early finding of cold stress?
- A. shivering
- B. hyperglycemia
- C. tachycardia
- D. bradypnea
Correct Answer: C
Rationale: Tachycardia is an early sign of cold stress as the infant attempts to increase metabolism to maintain body temperature.
The nurse assesses the new stoma of a client diagnosed with Crohn's disease. Which of these assessment findings will alert the nurse that the stoma has retracted?
- A. Narrowed and flattened
- B. Concave and bowl-shaped
- C. Dry and reddish-purple
- D. Pinkish-red and moist
Correct Answer: B
Rationale: A retracted stoma appears concave and bowl-shaped, indicating it has pulled below the skin surface.
The nurse is caring for a child diagnosed with Tetralogy of Fallot. The client has had multiple hypercyanotic episodes (tet spells). The nurse anticipates that the physician will prescribe
- A. morphine sulfate
- B. adenosine
- C. diltiazem
- D. atropine sulfate
Correct Answer: A
Rationale: Morphine sulfate is used to manage tet spells by reducing oxygen demand and relaxing the child.