Saunders Chapter 1
The nurse monitors a client receiving digoxin for which early manifestation of digoxin toxicity? 1. Anorexia 2. Facial pain 3. Photophobia 4. Yellow color perception
1. Anorexia Digoxin is a cardiac glycoside that is used to manage and treat heart failure and to control ventricular rates in clients with atrial fibrillation. The most common early manifestations of toxicity include gastrointestinal disturbances such as anorexia, nausea, and vomiting. Neurological abnormalities can also occur early and include fatigue, headache, depression, weakness, drowsiness, confusion, and nightmares. Facial pain, personality changes, and ocular disturbances (photophobia, diplopia, light flashes, halos around bright objects, yellow or green perception) are also signs of toxicity, but are not early signs.
The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. On the basis of these findings, the nurse should implement which action? 1. Remove the IV. 2. Apply a warm compress. 3. Check for a blood return. 4. Measure the area of infiltration.
1. Remove the IV. The client is experiencing infiltration so consider the harmful effects of infiltration and determine the action to implement. Because infiltration can be damaging to the surrounding tissue, the appropriate action is to remove the IV to prevent any further damage. Once the IV is removed, further action should be taken depending on the medication infusion at the time of infiltration based on agency protocol, but may include aspiration of the fluid from the site, injection of an antidote, application of warm or cool compresses for specific time intervals, and elevation of the extremity.
The nurse prepares to care for a client on contact precautions who has a hospital-acquired infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator, which requires frequent suctioning. The nurse should assemble which necessary protective items before entering the client's room? 1. Gloves and gown 2. Gloves and face shield 3. Gloves, gown, and face shield 4. Gloves, gown, and shoe protectors
3. Glove, gown, and face shield The question addresses content related to protecting oneself from contracting an infection and requires that you consider the methods of possible transmission of infection, based on the client's condition. Because of the potential for splashes of infective material occurring during the wound irrigation or suctioning of the tracheostomy, option 3 is correct.
The nurse is choosing age-appropriate toys for a toddler. Which toy is the best choice for this age? 1. Puzzle 2. Toy soldiers 3. Large stacking blocks 4. A card game with large pictures
3. Large stacking blocks Toddlers like to master activities independently, such as stacking blocks. Because toddlers do not have the developmental ability to determine what could be harmful, toys that are safe need to be provided. A puzzle and toy soldiers provide objects that can be placed in the mouth and may be harmful for a toddler. A card game with large pictures may require cooperative play, which is more appropriate for a school-age child.
A client with Parkinson's disease develops akinesia while ambulating, increasing the risk for falls. Which suggestion should the nurse provide to the client to alleviate this problem? 1. Use a wheelchair to move around. 2. Stand erect and use a cane to ambulate. 3. Keep the feet close together while ambulating and use a walker. 4. Consciously think about walking over imaginary lines on the floor.
4. Consciously think about walking over imaginary lines on the floor. The question addresses client mobility and promoting assistance in an activity of daily living to maintain safety. Focus on the subject, akinesia. Clients with Parkinson's disease can develop bradykinesia (slow movement) or akinesia (freezing or no movement). Having these clients imagine lines on the floor to walk over can keep them moving forward while remaining safe.
The nurse has received the client assignment for the day. Which client should the nurse assess first? 1. The client who needs to receive subcutaneous insulin before breakfast 2. The client who has a nasogastric tube attached to intermittent suction 3. The client who is 2 days postoperative and is complaining of incisional pain 4. The client who has a blood glucose level of 50 mg/dL (2.8 mmol/L) and complaints of blurred vision
4. The client who has a blood glucose level of 50 mg/dL (2.8 mmol/L) and complaints of blurred vision Compare the needs of each client and decide which need is urgent. The client has a low blood glucose level and symptoms reflects of hypoglycemia. The client should be assessed first so that treatment can be implemented. The other clients have needs that require assessment, but their assessments can wait until the correct client is stabilized.
A client with end-stage chronic obstructive pulmonary disease has selected guided imagery to help cope with psychological stress. Which client statement indicates an understanding of this stress-reduction measure? 1. "This will help only if I play music at the same time." 2. "This will work for me only if I am alone in a quiet area." 3. "I need to do this only when I lie down in case I fall asleep." 4. "The best thing about this is that I can use it anywhere anytime."
4. "The best thing about this is that I can use it anywhere anytime." Guided imagery involves the client creating an image in the mind, concentrating on the image, and gradually becoming less aware of the offending stimulus. It can be done anytime and anywhere; some clients may use other relaxation techniques or play music with it.
