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The nurse is preparing to administer digoxin (Lanoxin) to a client with heart failure. The client's apical pulse is 58 bpm. What should the nurse do next?
- A. Administer the dose as ordered
- B. Withhold the dose and notify the physician
- C. Reduce the dose by half
- D. Recheck the pulse in 30 minutes
Correct Answer: B
Rationale: Digoxin is typically withheld if the apical pulse is below 60 bpm in adults, as bradycardia may indicate toxicity. The physician should be notified for further evaluation.
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A hospice nurse is caring for a client with breast cancer and brain metastasis. The nurse is reviewing the lab report below. According to the information in the chart, what should the nurse do next?
- A. Document these results on the medical record.
- B. Report the elevated potassium level immediately.
- C. Report the elevated calcium level immediately.
- D. Refrain from reporting the results because the client is in hospice care.
Correct Answer: C
Rationale: The normal calcium level is 9.0 to 10.5 mg/dL. Hypercalcemia is commonly seen with malignant disease and metastases. The other laboratory values are normal. Hypercalcemia can be treated with fluids, furosemide (Lasix), or administration of calcitonin. Failure to treat hypercalcemia can cause muscle weakness, changes in level of consciousness, nausea, vomiting, abdominal pain, and dehydration. Although the client is on hospice care, she will still need palliative treatment. Comfort and risk reduction are components of hospice care.
A client is trying to lose weight at a moderate pace. The client eliminates 1,000 calories per day from his normal intake, how many pounds would he lose in 1 week?
- A. 2
- B. 3
- C. 4
- D. 5
Correct Answer: A
Rationale: A 1,000-calorie daily deficit equals 7,000 calories per week. Since 3,500 calories approximate one pound of fat, the client would lose about 2 pounds per week.
The nurse assesses for euphoria in a client with multiple sclerosis, looking for which of the following characteristic clinical manifestations?
- A. Inappropriate laughter.
- B. An exaggerated sense of well-being.
- C. Slurring of words when excited.
- D. Visual hallucinations.
Correct Answer: B
Rationale: Euphoria in multiple sclerosis is characterized by an exaggerated sense of well-being, often disproportionate to the client's condition.
The nurse establishes the goal of preventing the development of a stress ulcer in a burn client. Which of the following interventions would most likely contribute to the achievement of this goal?
- A. Implementing relaxation exercises.
- B. Administering a sedative as needed.
- C. Administering prophylactic antacids or histamine-2 receptor antagonists.
- D. Monitoring the client's nutritional status closely.
Correct Answer: C
Rationale: Prophylactic antacids or H2 receptor antagonists reduce gastric acid, preventing stress ulcers in burn patients, who are at high risk due to stress response.
You are the chair person for the healthcare facility's newly formed multidisciplinary Safety Committee. During the Forming stage of this group's development major conflicts have arisen. Which technique of conflict resolution should you use to resolve these conflicts?
- A. Passivity
- B. Compromise
- C. Competition
- D. Accommodating Others
Correct Answer: B
Rationale: During the Forming stage, where group members are establishing relationships, compromise is the most effective conflict resolution technique to promote collaboration and consensus while addressing conflicts constructively.