Nokea
The nurse is transcribing the doctor’s orders for a client with congestive heart failure. The order reads 2.5 mg of Lanoxin daily. Which action should the nurse implement?
- A. Discuss the order with the health-care provider.
- B. Take the client’s apical pulse rate before administering.
- C. Check the client’s potassium level before giving the medication.
- D. Determine if a digoxin level has been drawn.
Correct Answer: A
Rationale: Lanoxin (digoxin) 2.5 mg (A) exceeds the safe dose (0.125–0.25 mg daily), requiring HCP clarification. Pulse (B), potassium (C), and digoxin level (D) are routine but secondary to dose error.
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Where is the correct placement for the nurse's hands before administering cardiac compressions?
- A. On the lower half of the sternum
- B. On the lower half of the xiphoid process
- C. Over the costal cartilage
- D. Directly above the manubrium
Correct Answer: A
Rationale: Hands are placed on the lower half of the sternum (center of the chest) for effective CPR compressions.
What should be included in the teaching plan for an adult who has hypertension?
- A. Reduce dietary calcium.
- B. Avoid aerobic exercise.
- C. Reduce alcohol intake.
- D. Limit fluid intake.
Correct Answer: C
Rationale: Reducing alcohol intake helps manage hypertension by lowering blood pressure. Calcium reduction, avoiding aerobic exercise, or limiting fluids are not standard recommendations.
Which symptom would the nurse expect to observe if the client is having an allergic reaction to streptokinase (Streptase)?
- A. Urticaria
- B. Anuria
- C. Hemoptysis
- D. Dyspepsia
Correct Answer: A
Rationale: Urticaria (hives) is a common sign of an allergic reaction to streptokinase, a thrombolytic agent.
Which client would most likely be misdiagnosed for having a myocardial infarction?
- A. A 55-year-old Caucasian male with crushing chest pain and diaphoresis.
- B. A 60-year-old Native American male with an elevated troponin level.
- C. A 40-year-old Hispanic female with a normal electrocardiogram.
- D. An 80-year-old Peruvian female with a normal CK-MB at 12 hours.
Correct Answer: C
Rationale: A 40-year-old Hispanic female with normal ECG (C) is most likely to be misdiagnosed, as women often present atypically and normal ECGs can occur in MI. Typical symptoms (A), elevated troponin (B), and normal CK-MB at 12 hours (D) are less likely to be missed.
The client is exhibiting sinus bradycardia, is complaining of syncope and weakness, and has a BP of 98/60. Which collaborative treatment should the nurse anticipate being implemented?
- A. Administer a thrombolytic medication.
- B. Assess the client's cardiovascular status.
- C. Prepare for insertion of a pacemaker.
- D. Obtain a permit for synchronized cardioversion.
Correct Answer: C
Rationale: Symptomatic bradycardia (syncope, hypotension) often requires a pacemaker (C). Thrombolytics (A) are for MI, assessment (B) is ongoing, and cardioversion (D) is for tachydysrhythmias.