Nokea
The nurse is teaching a client about the toxicity of digoxin. Which one of the following statements made by the client to the nurse indicates more teaching is needed?
- A. I may experience a loss of appetite.'
- B. I can expect occasional double vision.'
- C. Nausea and vomiting may last a few days.'
- D. I must report a bounding pulse of 62 immediately.'
Correct Answer: D
Rationale: Slow heart rate is related to increased cardiac output and an intended effect of digoxin. The ideal heart rate is above 60 BPM with digoxin. The client needs further teaching.
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The nurse is caring for a client who is postoperative day 1 after a lumbar laminectomy. Which of the following actions should the nurse prioritize?
- A. Encourage log-rolling when repositioning
- B. Administer pain medication as needed
- C. Keep the head of the bed elevated 45 degrees
- D. Monitor the surgical drain for output
Correct Answer: A
Rationale: Log-rolling maintains spinal alignment, preventing complications post-laminectomy. Options B, C, and D are secondary: pain management is routine, 45-degree elevation is excessive, and drain monitoring is less urgent.
The nurse is caring for a client with a history of bipolar disorder.
- A. Which client statement indicates a need for further teaching about lithium therapy?
- B. I’ll drink plenty of water every day.'
- C. I’ll have my blood levels checked regularly.'
- D. I can stop the medication if I feel better.'
- E. I’ll avoid eating foods high in sodium.'
Correct Answer: C
Rationale: Stating that the medication can be stopped when feeling better indicates a misunderstanding, as lithium requires consistent use to maintain therapeutic levels and prevent mood swings. Hydration, blood monitoring, and sodium awareness are correct.
A client hospitalized with a fractured mandible is to be discharged. Which piece of equipment should be kept on the client with a fractured mandible?
- A. Wire cutters
- B. Oral airway
- C. Pliers
- D. Tracheostomy set
Correct Answer: A
Rationale: Wire cutters are essential for a fractured mandible with wiring, in case of emergency airway obstruction. Oral airway , pliers , and tracheostomy set are not standard.
In teaching parents to associate prevention with the lifestyle of their child with sickle cell disease, the nurse should emphasize that a priority for their child is to
- A. Avoid overheating during physical activities
- B. Maintain normal activity with some restrictions
- C. Be cautious of others with viruses or temperatures
- D. Maintain routine immunizations
Correct Answer: A
Rationale: Avoid overheating during physical activities. Dehydration from overheating can trigger a sickle cell crisis.
A nurse is caring for a 37-year-old woman with metastatic ovarian cancer admitted for nausea and vomiting.
- A. What is the best indication that the nutritional status of a woman with metastatic ovarian cancer has improved after 4 days of TPN?
- B. The patient eats most of the food served to her.
- C. The patient has gained 1 pound since admission.
- D. The patient’s albumin level is 0 mg/dL.
- E. The patient’s hemoglobin is 8.5 g/dL.
Correct Answer: C
Rationale: Albumin levels (normal 5–5.0 g/dL) are the best indicator of long-term nutritional status, reflecting protein stores. A level of 0 mg/dL indicates improved nutrition. Eating more, weight gain (which may be fluid), or hemoglobin levels (affected by cancer or chemotherapy) are less reliable indicators.