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Which lab value is most critical to monitor in a patient receiving digoxin?
- A. Monitor potassium levels
- B. Monitor sodium levels
- C. Monitor calcium levels
- D. Monitor magnesium levels
Correct Answer: A
Rationale: The correct answer is to monitor potassium levels in a patient receiving digoxin. Hypokalemia can potentiate the toxic effects of digoxin, leading to serious cardiac arrhythmias. Monitoring potassium levels helps prevent toxicity. Monitoring sodium levels (Choice B), calcium levels (Choice C), and magnesium levels (Choice D) are also important aspects of patient care, but potassium levels are most critical in patients on digoxin therapy.
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A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse expect?
- A. Barrel-shaped chest
- B. Bradycardia
- C. Increased respiratory rate
- D. Tracheal deviation
Correct Answer: C
Rationale: Corrected Rationale: An increased respiratory rate is a common finding in clients with ARDS as the body attempts to compensate for impaired gas exchange. Barrel-shaped chest (Choice A) is associated with conditions like COPD, not ARDS. Bradycardia (Choice B) is unlikely in ARDS due to the body's compensatory mechanisms to improve oxygenation. Tracheal deviation (Choice D) is not typically seen in ARDS and is more suggestive of other respiratory conditions.
What is the best nursing action for a patient experiencing shortness of breath?
- A. Administer oxygen
- B. Administer bronchodilators
- C. Reposition the patient
- D. Provide IV fluids
Correct Answer: A
Rationale: Administering oxygen is the best nursing action for a patient experiencing shortness of breath as it helps alleviate the symptoms and improve oxygenation. Providing oxygen addresses the primary issue of inadequate oxygen levels in the body, which can be a life-threatening situation. Administering bronchodilators (choice B) may be appropriate for specific respiratory conditions like asthma but is not the initial intervention for all causes of shortness of breath. Repositioning the patient (choice C) can sometimes help improve breathing, but in a patient experiencing significant shortness of breath, immediate oxygen therapy is crucial. Providing IV fluids (choice D) is not indicated as the first-line intervention for shortness of breath unless there is a specific underlying cause such as dehydration.
A nurse is providing discharge instructions for a client who has osteoporosis. Which of the following instructions should the nurse include to prevent injury?
- A. Perform weight-bearing exercises.
- B. Avoid crossing the legs beyond the midline.
- C. Avoid sitting in one position for prolonged periods.
- D. Splint the affected area.
Correct Answer: A
Rationale: The correct answer is A: Perform weight-bearing exercises. Weight-bearing exercises are crucial for preventing bone density loss in clients with osteoporosis. These exercises help strengthen bones and reduce the risk of fractures. Option B, avoiding crossing the legs beyond the midline, is not directly related to preventing injury in osteoporosis. Option C, avoiding sitting in one position for prolonged periods, is important for preventing pressure ulcers but does not specifically address preventing injury in osteoporosis. Option D, splinting the affected area, is not a standard recommendation for preventing injury in osteoporosis.
How should a healthcare provider care for a patient with a tracheostomy?
- A. Clean the tracheostomy site daily
- B. Change the tracheostomy ties daily
- C. Suction the tracheostomy regularly
- D. Provide humidified oxygen
Correct Answer: C
Rationale: Suctioning the tracheostomy regularly is crucial in caring for a patient with a tracheostomy as it helps keep the airway clear of secretions, preventing blockages and potential complications. Cleaning the tracheostomy site daily is important for hygiene but not as critical as regular suctioning. Changing the tracheostomy ties daily may not be necessary unless soiled or loose. Providing humidified oxygen may be part of the care plan but is not as directly related to maintaining the tracheostomy patency as suctioning.
A client at 10 weeks of gestation reports frequent nausea and vomiting. Which of the following instructions should the nurse include?
- A. Eat high-protein foods.
- B. Lie down after meals.
- C. Drink water with meals.
- D. Eat dry carbohydrates before getting out of bed.
Correct Answer: D
Rationale: During early pregnancy, nausea and vomiting are common. Instructing the client to eat dry carbohydrates like crackers before getting out of bed can help alleviate these symptoms. This recommendation helps prevent an empty stomach, which can worsen nausea. High-protein foods (Choice A) may be harder to digest and could exacerbate nausea. Lying down after meals (Choice B) may increase gastric reflux and worsen symptoms. Drinking water with meals (Choice C) may make the client feel fuller, potentially worsening nausea.