Nokea
The nurse is to administer Lanoxin(digoxin) elixir to a 6-month old with a congenital heart defect. The nurse auscultates an apical pulse rate of 100 . The nurse should:
- A. Record the heart rate and call the physician.
- B. Record the heart rate and administer the medication.
- C. Administer the medication and recheck the heart rate in 15 minutes.
- D. Hold the medication and recheck the heart rate in 30 minutes.
Correct Answer: B
Rationale: A pulse of 100 in a 6-month-old is normal (80-150 bpm), so the nurse should administer digoxin . Calling the physician or holding the dose is unnecessary. Rechecking later is not standard.
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Which of the following nursing interventions is MOST important when caring for a client who has just been placed in physical restraints?
- A. Prepare PRN dose of psychotropic medication.
- B. Check that the restraints have been applied correctly.
- C. Review hospital policy regarding duration of restraints.
- D. Monitor the client's needs for hydration and nutrition while restrained.
Correct Answer: B
Rationale: assessment; while a client is restrained, physiological integrity is important; monitoring positioning, tightness, and peripheral circulation is essential; nurse documents the client's response and clinical status after being restrained
The nurse is teaching a client with a new diagnosis of Parkinson’s disease about levodopa-carbidopa (Sinemet). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication on an empty stomach.
- B. I should avoid high-protein meals with this medication.
- C. I should report any muscle twitching to my doctor.
- D. I should expect my urine to turn dark.
Correct Answer: D
Rationale: Dark urine is not an expected side effect of levodopa-carbidopa; it may indicate another issue, such as hematuria, requiring investigation. Options A, B, and C are correct: taking on an empty stomach improves absorption, high-protein meals interfere with efficacy, and muscle twitching may indicate toxicity.
An elderly client with osteoarthritis.
The homecare nurse is visiting an elderly client with osteoarthritis. It would be MOST important for the nurse to include which of the following instructions?
- A. Swimming is the only helpful exercise for osteoarthritis.
- B. Warm-up exercises should be done prior to exercising.
- C. Exercises should be done routinely, even if severe joint pain occurs.
- D. Isometric exercises are most helpful to prevent contractures.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) swimming is only one helpful exercise (2) correct-warm-up or 'stretching' exercises should always be done to begin and end exercising (3) severely painful joints should not be exercised (4) isometric exercises do not involve joint movement
Which vitamin is directly involved in the metabolism of the hormones secreted by the parathyroid?
- A. Vitamin C
- B. Vitamin D
- C. Vitamin K
- D. Vitamin B9
Correct Answer: B
Rationale: Vitamin D is critical for calcium absorption, which is regulated by parathyroid hormones. Vitamins C, K, and B9 are not directly involved.
A nurse is assessing a patient in the rehab unit at shift change. The patient has suffered a TBI 3 weeks ago. Which of the following is the most distinguishing characteristic of a neurological disturbance?
- A. LOC (level of consciousness)
- B. Short term memory
- C. #NAME?
- D. #NAME?
Correct Answer: A
Rationale: LOC is the most critical indicator of impaired neurological capabilities.