Nokea
The nurse is preparing to administer the morning dose of digoxin, a cardiac glycoside, to a client diagnosed with congestive heart failure. Which data would indicate the medication is effective?
- A. The apical heart rate is 72 beats per minute.
- B. The client denies having any anorexia or nausea.
- C. The client's blood pressure is 120/80 mm Hg.
- D. The client's lungs sounds are clear bilaterally.
Correct Answer: D
Rationale: Clear lung sounds indicate reduced fluid overload in CHF, a sign of digoxin’s effectiveness in improving cardiac output. HR, nausea, or BP are less specific.
You may also like to solve these questions
An adult client is on call for the operating room. The preoperative medication order is for meperidine HCl (Demerol) 100 mg IM and atropine 0.4 mg IM. The operating room calls at 11:00 A.M. and requests that the client be medicated. The nurse notes that the client last received meperidine for pain at 10:00 A.M. What is the most appropriate action for the nurse to take?
- A. Give the preoperative medication as ordered
- B. Give half the dose of meperidine and all of the atropine
- C. Check with the anesthesiologist before administering the medication
- D. Withhold both the meperidine and the atropine
Correct Answer: C
Rationale: Recent meperidine administration increases the risk of respiratory depression. Consulting the anesthesiologist ensures safe dosing.
The nurse has received the morning report and has the following medications due or being requested. In which order should the nurse administer the medications? List in order of priority.
- A. Administer furosemide (Lasix), a loop diuretic, IVP daily to a client diagnosed with heart failure who is dyspneic on exertion.
- B. Administer morphine, a narcotic analgesic, IVP prn to a client diagnosed with lower back pain who is complaining of pain at a '10' on a 1-to-10 scale.
- C. Administer neostigmine (Prostigmin), a cholinesterase inhibitor, PO to a client diagnosed with myasthenia gravis.
- D. Administer lidocaine, an antidysrhythmic, IVP prn to a client in normal sinus rhythm with multifocal premature ventricular contractions.
- E. Administer vancomycin, an aminoglycoside antibiotic, to a client diagnosed with a Staphylococcus infection who has a trough level of 14 mg/dL.
Correct Answer: B,D,A,C,E
Rationale: 1) Morphine for severe pain (acute, 10/10); 2) Lidocaine for PVCs (cardiac risk); 3) Furosemide for dyspnea (respiratory distress); 4) Neostigmine for myasthenia (muscle strength); 5) Vancomycin (infection, stable trough).
The nurse is preparing to administer Synthroid, a thyroid hormone replacement, to the client diagnosed with hypothyroidism. Which assessment data would indicate the client is receiving too much medication?
- A. Bradypnea and weight gain.
- B. Lethargy and hypotension.
- C. Irritability and tachycardia.
- D. Normothermia and constipation.
Correct Answer: C
Rationale: Excess Synthroid causes hyperthyroidism symptoms like irritability and tachycardia. Bradypnea, lethargy, or constipation suggest hypothyroidism.
The employee health nurse is observing a student nurse administer a PPD tuberculin test to a new employee. Which behavior would warrant immediate intervention by the employee health nurse?
- A. The student nurse inserts the needle at a 45-degree angle.
- B. The student nurse cleanses the forearm with alcohol.
- C. The student nurse circles the injection site with ink.
- D. The student nurse instructs the employee to return in three (3) days.
Correct Answer: A
Rationale: PPD tests require a 10–15-degree angle for intradermal injection to form a wheal; 45 degrees is incorrect and warrants intervention. Other actions are standard.
An adult client has pulmonary tuberculosis. He is receiving INH 300 mg PO, ethambutol 1 g PO daily, and streptomycin 1 g IM three times a week. When he comes in for a checkup, he tells the nurse that he hates getting shots and his ears ring most of the time. What advice does the nurse expect will be given to this client?
- A. Take pyridoxine daily.
- B. Expect red-colored urine and feces.
- C. Stop the medications when your cough is gone.
- D. Take streptomycin by mouth instead of by injection.
Correct Answer: B
Rationale: Streptomycin’s ototoxicity may require discontinuation, not pyridoxine (used for INH). Red urine/feces is expected with rifampin, not listed here, but monitoring is key.