Nokea
Which of the following menu choices would indicate that a client with pressure ulcers understands the role diet plays in restoring her albumin levels?
- A. Broiled fish with rice
- B. Bran flakes with fresh peaches
- C. Lasagna with garlic bread
- D. Cauliflower and lettuce salad
Correct Answer: A
Rationale: Broiled fish and rice are excellent protein sources, aiding in restoring albumin levels for tissue repair. The other options are lower in protein.
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Prior to administering digoxin to a client with congestive heart failure, the nurse needs to assess:
- A. Respiratory rate for 1 minute
- B. Radial pulse for 1 minute
- C. Radial pulse for 2 minutes
- D. Apical pulse for 1 minute
Correct Answer: D
Rationale: Apical pulse should be measured for 1-minute prior to digoxin administration. Digoxin decreases the heart rate. Digoxin should be withheld if apical rates are <60 bpm or >120 bpm.
Prior to his discharge from the hospital, a cardiac client is started on digoxin (Lanoxin) 25 mg po qd. The nurse initiates discharge teaching. Which of the following statements by the client would validate an understanding of his medication?
- A. I would notify my physician immediately if I experience nausea, vomiting, and double vision.'
- B. I could stop taking this medication when I begin to feel better.'
- C. I should only take the medication if my heart rate is greater than 100 bpm.'
- D. I should always take this medication with an antacid.'
Correct Answer: A
Rationale: The first signs of digoxin toxicity include abdominal pain, anorexia, nausea, vomiting, and visual disturbances. The physician should be notified if any of these symptoms are experienced. The positive inotropic effects of digoxin increase cardiac output and result in an enhanced activity tolerance. 'Feeling better' indicates the drug is working and medication therapy must be continued. Clients should be taught to take their pulse prior to taking the digoxin. If their pulse rate becomes irregular, slows significantly, or is >100 bpm the physician should be notified. Antacids decrease the effectiveness of digoxin.
A premature infant needs supplemental O2 therapy. A nursing intervention that reduces the risk of retrolental fibroplasia is to:
- A. Maintain O2 at <40%
- B. Maintain O2 at >40%
- C. Give moist O2 at >40%
- D. Maintain on 100% O2
Correct Answer: A
Rationale: Maintaining O2 at <40% minimizes the risk of retrolental fibroplasia, a complication of high oxygen levels in premature infants.
A client with increased intracranial pressure is receiving Osmitrol (Mannitol) and Furosemide (Lasix). The nurse recognizes that these two drugs are given to reverse which effect?
- A. Energy failure
- B. Excessive intracellular calcium
- C. Cellular edema
- D. Excessive glutamate release
Correct Answer: C
Rationale: Mannitol and Furosemide reduce cellular edema by promoting diuresis and osmotic fluid shifts, lowering ICP. Energy failure (A), calcium (B), and glutamate (D) are not directly targeted.
The nurse is caring for a 6-week-old girl with meningitis. To help her develop a sense of trust, the nurse should:
- A. Give her a small soft blanket to hold
- B. Give her good perineal care after each diaper change
- C. Leave the door open to her room
- D. Pick her up when she cries
Correct Answer: D
Rationale: A soft blanket may be comforting, but it is not directed toward developing a sense of trust. Good perineal care is important, but it is not directed toward developing a sense of trust. An infant with meningitis needs frequent attention, but leaving the door open does not foster trust. Consistently picking her up when she cries will help the child feel trust in her caregivers.