Nokea
The nurse recognizes that which factors place a client at increased risk for falls? Select all that apply.
- A. Age of 50
- B. Diagnosis of ovarian cancer
- C. Lying pulse 80/min, standing pulse 110/min
- D. Osteoarthritis of knees
- E. Takes carbidopa/levodopa
- F. Uses a cane to ambulate
Correct Answer: C,D,E
Rationale: Orthostatic pulse change (C) indicates cardiovascular instability, increasing fall risk. Osteoarthritis of knees (D) impairs mobility and stability. Carbidopa/levodopa (E) for Parkinson’s can cause orthostatic hypotension or dyskinesia, heightening fall risk. Age 50 (A) is not a significant risk factor alone, ovarian cancer (B) is unrelated to falls, and cane use (F) reduces risk if used correctly.
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A client taking Zoloft (sertraline) tells the nurse that she has also been taking St. John's wort. The nurse should report this information to the doctor because:
- A. The two substances have opposing effects.
- B. The amount of medication may be reduced.
- C. Herbals only provide a placebo effect.
- D. It will be necessary to increase the dosage.
Correct Answer: B
Rationale: St. John's wort can induce the metabolism of Zoloft, potentially reducing its effectiveness, so the doctor may need to adjust the dose. Answer A is incorrect as they do not have opposing effects. Answer C is incorrect as St. John's wort has pharmacological effects. Answer D is incorrect as increasing the dose may not be necessary.
The nurse is making a home visit to an adult who had a cataract extraction yesterday. Which observation indicates that the client needs more instruction?
- A. The client demonstrates putting eye drops in the conjunctival sac.
- B. The client has a patch on the affected eye.
- C. The client bends over to pick up the cat.
- D. The client is wearing slip-on shoes.
Correct Answer: C
Rationale: Bending over post-cataract surgery increases intraocular pressure, risking complications; this indicates a need for further instruction on activity restrictions.
The nurse is completing a client's intake and output record for the shift. How many mL should the nurse record as the client's net fluid balance for the shift?
Correct Answer: 890
Rationale: Without specific intake/output data, a general approach is assumed: net fluid balance is calculated as total intake (IV, oral, etc.) minus total output (urine, emesis, etc.). For example, if intake is 2000 mL and output is 1800 mL, the balance is 200 mL. The nurse must sum all recorded values accurately.
A client on hospice home care is taking sips of water but refusing food. Family members appear distressed and insist that the personal care worker 'force feed' the client. What is the priority nursing action?
- A. Explain to the family that this is a normal physiological response to dying
- B. Explore the family’s thoughts and concerns about the client’s refusal of food
- C. Recommend a feeding tube
- D. Tell the family that 'force feeding' the client could cause the client to choke on the food
Correct Answer: A
Rationale: Explaining that anorexia is normal in dying (A) addresses family distress and aligns with hospice goals. Exploring concerns (B) is secondary, feeding tubes (C) are inappropriate, and choking warnings (D) may escalate distress.
A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider?
- A. Blood pressure 94/60
- B. Heart rate 76 BPM
- C. Urine output 50 ml/hour
- D. Respiratory rate 16
Correct Answer: A
Rationale: Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60-100 BPM; systolic B/P over 100) in order to safely administer both medications.