Nokea
The nurse is reviewing the chart illustrated of the client diagnosed with stage III HF. Which conclusion should the nurse make?
- A. The medications should be administered as prescribed.
- B. The client may be experiencing toxicity from digoxin.
- C. Hyperkalemia likely caused the client's cardiac dysrhythmias.
- D. Seeing halos can result from the atrial fibrillation or anticoagulants.
Correct Answer: B
Rationale: A: The digoxin should be withheld and not given until a serum digoxin level is determined. B: Signs of digoxin (Lanoxin) toxicity include seeing yellow halos around objects and dysrhythmias. The furosemide (Lasix) diuretic increases urinary excretion of potassium and can cause hypokalemia. Hypokalemia can contribute to both cardiac dysrhythmias and digoxin toxicity. C: A serum potassium level of 2.9 mEq/L indicates hypokalemia, not hyperkalemia. D: The yellow vision is a characteristic sign of digoxin toxicity and is not a sign of cerebral damage from an infarct due to atrial fibrillation or bleeding from the anticoagulants.
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The client has been successful at controlling gastroesophageal reflux symptoms without prescription medications. Which OTC medication should the nurse explore whether the client is taking for symptom control?
- A. Aspirin once a day
- B. Famotidine
- C. Ibuprofen
- D. Desloratadine
Correct Answer: B
Rationale: A: Aspirin increases gastric acid secretion and may worsen symptoms. B: The nurse should explore whether the client is taking famotidine (Pepcid) for symptom control. Famotidine blocks histamine-2 receptors on parietal cells, thus decreasing gastric acid production. C: NSAIDs, such as ibuprofen (Motrin), do not reduce gastric acid. D: Desloratadine (Clarinex) blocks only histamine-1 receptors and is not effective against histamine-2 receptors.
The nurse is assessing the child's ear with an otoscope prior to administering medications to treat persistent otitis media. Which assessment finding should the nurse expect?
- A. otoscope_1.PNG
- B. otoscope_2.PNG
- C. otoscope_3.PNG
- D. otoscope_4.PNG
Correct Answer: A
Rationale: A: This shows otitis media characterized by a bulging contour to the tympanic membrane, unclear ossicular landmarks, and yellowish middle ear effusion. B: This shows a perforated tympanic membrane, not otitis media. C: This shows a normal left ear tympanic membrane. The ossicular landmarks can be identified through the tympanic membrane. The nurse would not expect to see a normal tympanic membrane when the child has persistent otitis media. D: This shows the presence of a foreign body in the ear canal.
Following a THR, the client asks the nurse, “Why am I receiving enoxaparin? With my last hip surgery, I was given a heparin injection.†What is the nurse's best response?
- A. Enoxaparin is less expensive for you and much easier to administer than the heparin.
- B. There is less risk of bleeding with enoxaparin, and it doesn't affect your laboratory results.
- C. Enoxaparin is a low-molecular-weight heparin that lasts twice as long as regular heparin.
- D. Enoxaparin can be administered orally, whereas heparin is administered only by injection.
Correct Answer: C
Rationale: A: The cost of enoxaparin is more than twice the cost of the equivalent dose of heparin per injection. Both are available in prefilled syringes for subcutaneous injection. B: Both enoxaparin and heparin increase aPTT, which affects clotting. C: Because enoxaparin is more specific in inhibiting active factor X, the response is more stable, and the effect is two to four times longer than that of heparin. D: Enoxaparin is only administered subcutaneously. Heparin can be administered both subcutaneously and intravenously.
A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is under way and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate?
- A. Administer O2.
- B. Turn the client on her left side.
- C. Notify the physician.
- D. No action is necessary.
Correct Answer: D
Rationale: It is an early deceleration as a result of head compression, and at this time no action is necessary. Close observation of the mother and baby is needed.
The clinic nurse is teaching the parent how to give eye drops to the 3-year-old who has bacterial conjunctivitis and purulent drainage out of both eyes, swollen eyelids, and inflamed conjunctiva. What information should the nurse provide?
- A. Restrain the child prior to administering the eye drops.
- B. Have the child sitting when administering the eye drops.
- C. Place the child in a head-down position to instill the eye drops.
- D. Obtain the child's cooperation by describing the procedure in detail.
Correct Answer: A
Rationale: A: It is necessary to secure the child prior to instilling eye drops to ensure that the child receives the entire prescribed dose. The child is likely to resist instillation of the eye drops because a child is told not to put anything in the eyes and is likely to remember painful experiences such as dust or a foreign object that has gotten into the eye. B: The child should be supine, not sitting, when instilling eye drops. C: The child should be supine, not in a head-down position, when instilling eye drops. D: Telling the child what is happening is important, but at the age of 3, a detailed explanation will not make the child more cooperative.