- (Topic 4)
A client is being treated for congestive heart failure. His medical regimen consists of digoxin (Lanoxin) 0.25 mg po daily and furosemide 20 mg po bid. Which laboratory test should the nurse monitor?
Correct Answer:
C
(A) Intake and output are not laboratory tests. (B) Serum calcium levels are not affected by digoxin or furosemide. (C) Furosemide is a non–potassium-sparing loop diuretic. Hypokalemia is a common side effect of furosemide and may enhance digoxin toxicity. (D) Serum magnesium levels are not affected by digoxin or furosemide.
- (Topic 4)
On admission to the inpatient unit, a 34-year-old client is able to follow simple directions, but with great difficulty.
He is worried about how he can keep clean in such a public place and repeatedly dusts his bureau, straightens his bed, and adjusts the clothes in his closet. The client is experiencing a severe level of anxiety. Which response by the nurse would be most therapeutic in initially attempting to reduce his anxiety?
Correct Answer:
B
(A) This statement is punitive. (B) Acknowledging the anxiety and channeling it into some positive activity is therapeutic. (C) The client cannot say ??why??; this statement puts the client on the defensive. (D) A rational approach, especially a judgmental one, is nontherapeutic.
- (Topic 4)
An infant with a congenital heart defect is being discharged with an order for the administration of digoxin elixir every 12 hours. The parents need to be taught when administering digoxin to the infant that:
Correct Answer:
C
(A) Occasionally the child may vomit. They should not repeat the dose because the amount of digoxin that was absorbed is un-known, and serum levels of digoxin that are too high are more dangerous than those that are temporarily too low. (B) To ensure that the entire dose of digoxin is received, never mix it with food or formula. (C) Vomiting, anorexia, and listlessness are all signs of digoxin toxicity and should be reported to the physician immediately. (D) If a dose is forgotten for more than 6 hours, the nurse should advise the parents to skip that dose and to continue the next dose as scheduled.
- (Topic 1)
A child is admitted to the emergency room with her mother. Her mother states that she has been exposed to chickenpox. During the assessment, the nurse would note a characteristic rash:
Correct Answer:
B
(A) A rash with vesicular scabs in all stages (macule, papule, vesicle, and crusts). (B) A rash that appears profusely on the trunk and sparsely on the extremities. (C) A rash that first appears on the neck and spreads downward is characteristic of rubeola and rubella.
(D) A rash, especially on the cheeks, that gives a ??slapped-cheek?? appearance is characteristic of roseola.
- (Topic 4)
To facilitate maximum air exchange, the nurse should position the client in:
Correct Answer:
B
(A) The high Fowler position does increase air exchange, but not to the extent of orthopneic position. (B) The orthopneic position is a sitting position that allows maximum lung expansion. (C) The prone position places pressure on diaphragm and does not promote maximum air exchange. (D) The flat-supine position places pressure on diaphragm by abdominal organs and does not promote maximum air exchange.
