Nokea
The nurse is preparing to administer digoxin (Lanoxin) to a client. The client's apical pulse is 56 beats per minute. Which of the following actions should the nurse take?
- A. Administer the medication as ordered.
- B. Hold the medication and notify the physician.
- C. Administer half the prescribed dose.
- D. Recheck the pulse in 30 minutes and then administer the medication.
Correct Answer: B
Rationale: digoxin is held if the apical pulse is below 60 beats per minute in adults to prevent toxicity
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The mother of an eight-month-old infant prepares to take her child home after treatment for bacterial meningitis. The mother confides to the nurse that she is afraid that her child will have brain damage as a result of his illness. Which of the following is the BEST response by the nurse?
- A. Trust your doctors. They are excellent pediatricians and will know what to look for.
- B. There is a 20% incidence of residual brain damage after this type of illness, but the odds are in your favor.
- C. It is an unlikely possibility, but if your child doesn't develop normally, your pediatrician will help you with any problems.
- D. You feel guilty about your son's illness, and that's understandable. You will feel better after you get home.
Correct Answer: C
Rationale: if treated early, good prognosis; may be complications and long-term effects (seizure disorders, hydrocephalus, impaired intelligence, visual and hearing defects), therapeutic response
The nurse plans care for a 25-year-old woman immediately after a cesarean section. Which of the following nursing goals is MOST important?
- A. Prevent infection.
- B. Prevent fluid and electrolyte imbalances.
- C. Provide for pain management.
- D. Prevent hazards of immobility.
Correct Answer: B
Rationale: hemorrhage and shock most life-threatening conditions that occur after surgery
The nurse is caring for clients in the hospital. Which of the following nursing activities BEST promotes rest for an elderly hospitalized client?
- A. Place a clock at the bedside.
- B. Restrict visitors so that the client is alone during the evening.
- C. Tell the client how to call for help if needed.
- D. Postpone explanation of further tests that the client will need.
Correct Answer: C
Rationale: elderly client who feels isolated and unable to obtain help if needed cannot rest properly
The nurse in a long-term care facility is reviewing the nurse's notes in a client's chart. The nurse would be MOST concerned by which of the following entries?
- A. Foley catheter draining clear urine and the pH is 6.5.
- B. The client's skin is blanched over the scapular areas.
- C. Vital signs are within normal limits.
- D. The client drinks three glasses of orange juice every day.
Correct Answer: B
Rationale: blanching or hyperemia that does not disappear in a short time is a warning sign of pressure ulcers
A client has an order for furosemide (Lasix) 40 mg IV push via a heparin lock. Which of the following nursing actions would be MOST appropriate?
- A. Use a 16- to 18-gauge 1-in needle for administration.
- B. Administer the medication over one to two minutes.
- C. One cc of 1:1,000 heparin flush should be administered before the medication.
- D. A primary IV should be started prior to medication administration.
Correct Answer: B
Rationale: furosemide (Lasix) given IV push should be administered slowly over one to two minutes