Nokea
The nurse should be especially alert for signs and symptoms of digoxin toxicity if serum levels indicate that the client has a:
- A. Low sodium level.
- B. High glucose level.
- C. High calcium level.
- D. Low potassium level.
Correct Answer: D
Rationale: Low potassium (hypokalemia) increases the risk of digoxin toxicity by enhancing digoxin's binding to cardiac cells, leading to arrhythmias.
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The nurse has been assigned to provide care for four clients at the beginning of the day shift. In what order should the nurse assess these clients?
- A. A client awaiting surgery for a hiatal hernia repair at 11 a.m.
- B. A client with suspected gastric cancer who is on nothing-by-mouth (NPO) status for tests.
- C. A client with peptic ulcer disease experiencing a sudden onset of acute stomach pain.
- D. A client who is requesting pain medication 2 days after surgery to repair a fractured jaw.
Correct Answer: C
Rationale: The client with sudden onset of acute stomach pain (C) should be assessed first, as this could indicate a serious complication like ulcer perforation. The other clients' conditions are less urgent: the hiatal hernia client is stable, the NPO client is awaiting tests, and the jaw surgery client's pain is expected postoperatively.
A client is on complete bed rest. The nurse should assess the client for risk for developing which of the following complications?
- A. Air embolus
- B. Fat embolus
- C. Stress fractures
- D. Thrombophlebitis
Correct Answer: D
Rationale: Complete bed rest increases the risk of thrombophlebitis due to venous stasis from immobility, promoting clot formation. Air embolus is rare, fat embolus is associated with fractures, and stress fractures result from repetitive trauma, not bed rest.
A client with neutropenia has an absolute neutrophil count of 900. What is the client's risk of infection?
- A. Normal risk.
- B. Moderate risk.
- C. High risk.
- D. Extremely high risk.
Correct Answer: C
Rationale: An absolute neutrophil count (ANC) of 900 indicates moderate to severe neutropenia (ANC <1,000). This places the client at high risk for infection, as neutrophils are critical for fighting pathogens. Normal risk is ANC >1,500, and extremely high risk is ANC <200.
A client post-lithotripsy asks about expected symptoms. The nurse should explain:
- A. Bruising at the site.
- B. Severe flank pain.
- C. Clear urine output.
- D. Fever above 102°F.
Correct Answer: A
Rationale: Bruising is common post-lithotripsy due to shock wave impact on tissues.
A client with a history of heart failure has bilateral +4 edema of her right ankle that extends up to midcalf. She is sitting out of bed and has her legs in a dependent position. Which of the following goals is the priority?
- A. Decrease venous congestion
- B. Maintain normal respirations
- C. Maintain body temperature
- D. Prevent injury to lower extremities
Correct Answer: A
Rationale: Bilateral edema in heart failure results from increased venous pressure and congestion due to impaired cardiac output. The priority goal is to decrease venous congestion (e.g., by elevating legs or using compression) to reduce edema and improve circulation. Respirations, temperature, and injury prevention are secondary in this context.