Nokea
The nurse is preparing to administer digoxin (Lanoxin) to a client with heart failure. Which finding would require the nurse to withhold the dose?
- A. Apical pulse of 56 beats per minute
- B. Blood pressure of 130/80 mmHg
- C. Potassium level of 4.0 mEq/L
- D. Serum digoxin level of 1.2 ng/mL
Correct Answer: A
Rationale: Digoxin is withheld if the apical pulse is below 60 beats per minute in adults, as bradycardia increases the risk of toxicity. The other findings are within normal ranges for digoxin administration.
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The nurse is caring for a client with a history of atrial fibrillation. Which medication is most likely to be prescribed to prevent thromboembolism?
- A. Warfarin (Coumadin)
- B. Aspirin
- C. Clopidogrel (Plavix)
- D. Heparin
Correct Answer: A
Rationale: Warfarin is commonly prescribed for atrial fibrillation to prevent thromboembolism by maintaining anticoagulation (target INR 2–3). Aspirin and clopidogrel are less effective, and heparin is used short-term.
A 23-year-old college student seeks medical attention at the college infirmary for complaints of severe fatigue. Her skin is pale, and she reports exertional dyspnea. She is admitted to the hospital with possible aplastic anemia. Laboratory values reflect anemia, and the client is prepared for a bone marrow biopsy. She refuses to sign the biopsy consent and states, 'Can't you just get the doctor to give me a transfusion and let me go. This weekend begins spring break, and I have plans to go to Florida.' At this time the nurse's greatest concern is that:
- A. The client may contract an infection as a result of being exposed to large crowds at spring break
- B. The client does not grasp the full impact of her illness
- C. The client may require transfusion before leaving for spring break
- D. The causative agent be identified and treatment begun
Correct Answer: B
Rationale: The client could contract an infection, but at this point it is not the most pertinent issue. The client's statement indicates that she does not grasp the full impact of her illness. Further client education must be given, along with allowing her to express her feelings regarding her illness. The client may require a transfusion, but this is a temporary measure because the causative agent has not been identified. Her feelings regarding her illness must be addressed in order for care to continue. A bone marrow is done first to make a definitive diagnosis; then treatment may begin.
A 45-year-old male client was admitted to a chemical dependency treatment center following legal problems related to alcohol abuse. He states, 'I know that alcohol is a problem for some people, but I can stop whenever I want to. I'm never sick or miss work, and no one can complain about me.' During the initial assessment, the best response by the nurse would be:
- A. The fact is you are an alcoholic or you wouldn't be here.
- B. I understand it took strength to admit yourself to the unit, and I will do my part to help you to stay alcohol-free.
- C. If you can stop drinking when you want to, why don't you stop?
- D. It's good that you can stop drinking when you want to.
Correct Answer: B
Rationale: Direct confrontation initially is nontherapeutic and may result in the client becoming frustrated and wanting to leave. A positive, supportive attitude builds trust, and identifying positive strength raises self-esteem. Offering help allows the client to feel that he is not alone in dealing with problems. Asking the client why or to give an explanation for his behavior puts him in a position of having to justify his behavior to the nurse. Giving approval or placing a value on feelings or a behavior may limit the client's freedom to behave in a way that may displease another. This response may lead to seeking praise instead of progress.
The nurse is caring for a client with a recent laparoscopic hemicolectomy. Which finding should be reported to the physician?
- A. Sluggish bowel sounds
- B. Pain and tenderness at the umbilicus
- C. Passage of small amount of liquid stool
- D. Increasing abdominal girth
Correct Answer: D
Rationale: Increasing abdominal girth post-hemicolectomy may indicate complications like bleeding, ileus, or perforation, requiring immediate physician notification. Sluggish bowel sounds, umbilical pain, and liquid stool are expected early post-op.
The nurse is performing discharge teaching to the parents of a seven-year-old who has been diagnosed with asthma. Which sports activity would be most appropriate for this client?
- A. Baseball
- B. Swimming
- C. Football
- D. Track
Correct Answer: B
Rationale: Swimming is ideal for asthma patients, as the warm, humid air reduces bronchospasm risk. Baseball (A), football (C), and track (D) involve outdoor or high-exertion activities that may trigger asthma.