Nokea
A client with an irregular pulse rate of 81 and a potassium level of 3.0 mEq/L has digoxin (Lanoxin) ordered.
Which of the following actions if taken by the nurse is BEST?
- A. Give the digoxin.
- B. Hold the digoxin.
- C. Notify the physician.
- D. Re-check the pulse.
Correct Answer: C
Rationale: Strategy: The topic of the question is unstated. (1) although the pulse is normal, level of potassium must be considered (2) notify physician about low potassium (3) correct-hypokalemia can precipitate digoxin toxicity; physician should be called to obtain order for potassium supplement (4) notify physician about the potassium level
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A client with chronic congestive heart failure should be instructed to contact the home health nurse if which finding occurs?
- A. Weight gain of 2 pounds or more in a 48 hour period
- B. Urinating 4 to 5 times each day
- C. A significant decrease in appetite
- D. Appearance of non-pitting ankle edema
Correct Answer: A
Rationale: Weight gain of 2 pounds or more in a 48 hour period. It is critical for clients to report and be treated for rapid weight gain, which indicates fluid retention and worsening heart failure.
Decentralized scheduling is used on a nursing unit. A chief advantage of this management strategy is that it:
- A. considers client and staff needs
- B. conserves time spent on planning
- C. frees the nurse manager to handle other priorities
- D. allows requests for special privileges
Correct Answer: A
Rationale: Decentralized staffing takes into consideration specific client needs and staff interests and abilities.
The multidisciplinary team decides to implement behavior modification with a client.
- A. What is the primary nursing action during implementation of behavior modification?
- B. Confirm that all staff members understand and comply with the treatment plan.
- C. Establish mutually agreed upon, realistic goals.
- D. Ensure that the potent recorders (rewards) are important to the client.
- E. Establish a fixed interval schedule for reinforcement.
Correct Answer: A
Rationale: Consistency in applying the behavior modification plan is critical for success. Confirming that all staff members understand and comply ensures consistent implementation, reducing manipulation by the client or staff. While setting goals, choosing rewards, and scheduling reinforcement are important, they are secondary to ensuring staff alignment.
The nurse is performing physical assessments on adolescents. What finding would the nurse anticipate concerning female growth spurts?
- A. They occur about 2 years earlier than for males.
- B. They begin about the same time for males.
- C. They begin just prior to the onset of puberty.
- D. They are characterized by an increase in height of 4 inches each year.
Correct Answer: A
Rationale: They occur about 2 years earlier than for males. Females experience a growth spurt about 2 years earlier than their male peers.
The nurse is caring for a client who has right-sided weakness and has been told to use a cane for walking. Which action by the client indicates that he can use a cane correctly?
- A. He holds the cane in his right hand and moves the cane with the right leg when walking.
- B. He moves the cane from hand to hand when walking.
- C. He carries the cane in his left hand and moves it at the same time he moves his right foot.
- D. He puts the cane forward and then moves the left foot forward followed by the right foot.
Correct Answer: C
Rationale: Holding the cane in the left (unaffected) hand and moving it with the right (weak) leg provides support, indicating correct use.