Nokea
The nurse is giving instructions to an adult client with heart failure who is beginning therapy with digoxin. To detect early complications of therapy, which action should the nurse teach the client to perform?
- A. Take the pulse daily.
- B. Have electrolyte levels drawn weekly.
- C. Monitor the blood pressure once a week.
- D. Measure the weight each morning before breakfast.
Correct Answer: A
Rationale: Daily pulse monitoring helps detect digoxin-related complications like bradycardia (pulse <60 beats/min) or tachycardia (>100 beats/min), which require provider notification. Weekly electrolyte levels, blood pressure monitoring, and daily weight are not specific to early digoxin complications.
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A client has a new prescription for timolol and the nurse provides medication instructions to the client. Which statement by the client indicates a need for further teaching regarding the instructions?
- A. I should change positions slowly.
- B. I need to report shortness of breath to the doctor.
- C. I need to taper or discontinue the medication when I feel well.
- D. I have enough medication on hand to last through weekends and vacations.
Correct Answer: C
Rationale: Timolol is a beta-adrenergic blocking agent. The client should not discontinue or change the medication dose. Common client teaching points about beta-adrenergic blocking agents include taking the pulse daily, holding it if the rate is less than 60 beats/min (and notifying the primary health care provider); changing positions slowly; and reporting shortness of breath. The client is also instructed to keep enough medication on hand, not take over-the-counter medications (especially decongestants, cough, and cold preparations) without consulting the primary health care provider, and carry medical identification that states that a beta-blocker is being taken.
A client diagnosed with chronic obstructive pulmonary disease (COPD) is admitted to the hospital with an exacerbation. Which factor contributed most to the change in client status?
- A. Decreased fat intake
- B. Decreased fluid intake
- C. Sleeping soundly during the night
- D. Anxiety about the upcoming pulmonologist visit
Correct Answer: B
Rationale: The client with exacerbation of COPD has ineffective coughing and excess sputum in the airways. The nurse assesses the client for contributing factors such as dehydration and a lack of knowledge of proper coughing techniques. The reduction of these factors helps limit exacerbations of the disease. Decreased fat intake, sleeping soundly, and anxiety related to scheduled pulmonologist visit are not directly associated with this change in condition.
The nurse has given the client with a nonplaster (fiberglass) leg cast instructions regarding cast care at home. The nurse determines that the client needs further teaching if the client makes which statement?
- A. I should avoid walking on wet, slippery floors.
- B. I'm not supposed to scratch the skin underneath the cast.
- C. It's all right to wipe dirt off of the top of the cast with a damp cloth.
- D. If the cast gets wet, I can dry it with a hair dryer turned to the hot setting.
Correct Answer: D
Rationale: Using a hair dryer on a hot setting to dry a wet fiberglass cast can cause burns or damage the cast. Avoiding slippery floors, not scratching under the cast, and wiping the cast with a damp cloth are correct care instructions.
The nurse is assessing a client who is suspected of having a diagnosis of testicular cancer. Which data will be most helpful for determining the client's risk for this type of cancer?
- A. Race
- B. Marital status
- C. Number of children
- D. Number of sexual partners
Correct Answer: A
Rationale: Race is a key risk factor for testicular cancer, with higher incidence in White males compared to other groups. Marital status, number of children, and sexual partners are not established risk factors for this cancer.
The nurse is discussing developmental stages with the mother of a six-month-old infant. Which statement indicates an unexpected deviation from normal development?
- A. The infant is walking alone by 15 months.
- B. The infant waves good-bye by 7 months.
- C. The infant rolls from the tummy to the side at 12 months.
- D. The infant transfers a toy from one hand to the other at age 9 months.
Correct Answer: C
Rationale: Rolling tummy to side should occur by 6 months; delay to 12 months is concerning. Other milestones are age-appropriate or expected later.