Nokea
The nurse should teach the client that signs of digoxin toxicity include which of the following?
- A. Rash over the chest and back.
- B. Increased appetite.
- C. Visual disturbances such as seeing yellow spots.
- D. Elevated blood pressure.
Correct Answer: C
Rationale: Visual disturbances, like seeing yellow spots (xanthopsia), are a hallmark of digoxin toxicity, requiring prompt reporting.
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What is a goal of care for a client with acute renal failure?
- A. Maintain urine output of 30 mL/hour.
- B. Keep potassium above 5.5 mEq/L.
- C. Increase protein intake.
- D. Limit ambulation.
Correct Answer: A
Rationale: Maintaining adequate urine output indicates improving renal function.
Bed rest is prescribed for a client with pneumonia during the acute phase of the illness. The nurse should determine the effectiveness of bed rest by assessing the client's:
- A. Decreased cellular demand for oxygen.
- B. Reduced episodes of coughing.
- C. Diminished pain when breathing deeply.
- D. Ability to expectorate secretions more easily.
Correct Answer: A
Rationale: Bed rest reduces oxygen demand by decreasing metabolic rate, aiding recovery in pneumonia. Reduced coughing, diminished pain, and easier expectoration are secondary benefits but not the primary measure of bed rest effectiveness.
A client with bladder cancer has lost an estimated 500 mL blood in the urine. The client's hemoglobin is 8.0 g/dL, and the physician orders a unit of packed blood cells. To administer the packed red blood cells, the nurse should:
- A. Attach the packed cells to the existing 19G I.V. of normal saline solution using Y tubing.
- B. Start an additional 22G I.V. site because the packed blood cells must be given in a separate line.
- C. Attach the packed blood cells to the existing 22G I.V. of 5% dextrose using Y tubing.
- D. Start an additional I.V. access device with a 22G Intracath.
Correct Answer: A
Rationale: Packed red blood cells should be administered via a 19G I.V. with normal saline using Y tubing to prevent hemolysis, which can occur with dextrose solutions.
The nurse is monitoring a client after an above-the-knee amputation and notes that blood has saturated through the client and the dressing. The nurse should immediately:
- A. Apply a tourniquet
- B. Assess vital signs
- C. Call the physician
- D. Elevate the surgical extremity with a large pillow
Correct Answer: C
Rationale: Blood saturating the dressing post-amputation suggests significant bleeding, a potential emergency. The nurse should immediately call the physician for evaluation and intervention. Applying a tourniquet is extreme and requires an order, assessing vital signs is secondary, and elevating with a pillow may not address the bleeding source.
When suctioning a tracheostomy or laryngectomy tube, the nurse should follow which of the following procedures?
- A. Use a sterile catheter each time the client is suctioned.
- B. Clean the catheter in sterile water after each use and reuse for no longer than 8 hours.
- C. Protect the catheter in sterile packaging between suctioning episodes.
- D. Use a clean catheter with each suctioning, and disinfect it in hydrogen peroxide between uses.
Correct Answer: A
Rationale: Using a sterile catheter each time minimizes infection risk in the airway. Reusing catheters, even if cleaned, increases infection risk.