Nokea
The nurse prepares to administer digoxin (Lanoxin) to a newborn with a diagnosis of heart failure and notes that the apical rate is 140 beats per minute. Which nursing action is appropriate?
- A. Hold the medication
- B. Administer the digoxin
- C. Notify the healthcare provider
- D. Recheck the apical rate in 1 hour
Correct Answer: B
Rationale: The correct answer is to administer the digoxin. An apical rate of 140 bpm is within the normal range for a newborn. Digoxin is commonly prescribed for heart failure in newborns to help improve cardiac function. Holding the medication or notifying the healthcare provider is not necessary as the heart rate is normal for a newborn. Rechecking the apical rate in 1 hour is not needed since the heart rate is within the expected range.
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A client is prescribed lisinopril (Zestril) for the treatment of hypertension. He asks the nurse about possible adverse effects. The nurse should inform him about which common adverse effects of angiotensin-converting enzyme (ACE) inhibitors?
- A. Constipation
- B. Dizziness
- C. Headache
- D. B, C
Correct Answer: D
Rationale: The correct answer is D: 'Dizziness' and 'Headache'. ACE inhibitors like lisinopril are known to cause these common side effects due to their blood pressure-lowering effects. Choice A, 'Constipation', is not a common adverse effect associated with ACE inhibitors. While constipation can be a side effect of some medications, it is not typically seen with ACE inhibitors. Therefore, options A and B are incorrect choices.
Identifying the strengths and weaknesses in the nursing care plan is part of which of the following steps in determining and fulfilling the patient's nursing care needs?
- A. Evaluation
- B. Planning
- C. Implementation
- D. Assessment
Correct Answer: A
Rationale: Correct. Evaluation involves assessing the effectiveness of the nursing care plan by identifying its strengths and weaknesses. This step helps in determining if the plan is meeting the patient's needs.
Choice B (Planning) is incorrect because planning involves developing the nursing care plan based on the assessment of the patient's needs.
Choice C (Implementation) is incorrect as it refers to putting the nursing care plan into action.
Choice D (Assessment) is incorrect as assessment is the initial step in the nursing process, involving data collection and analysis to identify the patient's needs.
The nurse is caring for clients on a cardiac floor. Which client should the nurse assess first?
- A. The client with three (3) unifocal PVCs in a minute
- B. The client diagnosed with coronary artery disease who wants to ambulate
- C. The client diagnosed with mitral valve prolapse with an audible S3
- D. The client diagnosed with pericarditis who is in normal sinus rhythm
Correct Answer: C
Rationale: The correct answer is C because an audible S3 in a client with mitral valve prolapse could indicate heart failure, which requires immediate assessment. Choice A is less urgent as occasional unifocal PVCs are common. Choice B is important but can be addressed after the client with an audible S3. Choice D, a client with pericarditis in normal sinus rhythm, is stable compared to a client with potential heart failure symptoms.
The client has recently been diagnosed with irritable bowel syndrome (IBS). Which intervention should the nurse teach the client to reduce symptoms?
- A. Instruct the client to avoid drinking fluids with meals
- B. Explain the need to decrease intake of flatus-forming foods
- C. Teach the client how to perform gentle perianal care
- D. Encourage the client to see a psychologist
Correct Answer: B
Rationale: The correct answer is B. Decreasing the intake of flatus-forming foods can help reduce symptoms of bloating and discomfort in IBS. This intervention focuses on dietary modifications that can positively impact the client's condition. Instructing the client to avoid drinking fluids with meals (choice A) may not directly address the underlying cause of IBS symptoms. Teaching perianal care (choice C) is important for hygiene but does not directly address IBS symptoms. Encouraging the client to see a psychologist (choice D) may be beneficial for managing stress or anxiety associated with IBS but does not directly target symptom reduction through dietary changes.
What is the mission of the Army Medical Department?
- A. Ensure that each soldier receives a physical examination each year
- B. Provide health care to areas of the U.S. declared disaster zones by the President
- C. Maintain the health of the Army and conserve its fighting strength
- D. Offer medical, dental, and veterinary education and training
Correct Answer: C
Rationale: The correct answer is C: 'Maintain the health of the Army and conserve its fighting strength.' This mission statement reflects the primary goal of the Army Medical Department, which is to ensure the overall health and readiness of military personnel. Choices A, B, and D are incorrect because they do not fully capture the core purpose of the Army Medical Department. While providing physical examinations, healthcare in disaster areas, and education/training are important aspects, the central mission is to uphold the health and combat readiness of the Army.