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NEW QUESTION 35
Prior to administering digoxin to a client with congestive heart failure, the nurse needs to assess:
- A. Radial pulse for 1 minute
- B. Respiratory rate for 1 minute
- C. Radial pulse for 2 minutes
- D. Apical pulse for 1 minute
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) Respiratory rate is not directly affected by digoxin therapy. (B) A radial pulse is not as accurate as an apical pulse. Dysrhythmias may not be detected. (C) A radial pulse is not as accurate as an apical pulse, regardless of assessment time. (D) 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.
NEW QUESTION 36
The most important reason to closely assess circumferential burns at least every hour is that they may result in:
- A. Hypovolemia
- B. Renal damage
- C. Loss of peripheral pulses
- D. Ventricular arrhythmias
Answer: C
Explanation:
(A) Hypovolemia could be a result of fluid loss from thermal injury, but not as a result of the circumferential injury. (B) Renal damage is typically seen because of prolonged hypovolemia or myoglobinuria. (C) Electrical injuries and electrolyte changes typically cause arrhythmias in the burn client. (D) Full-thickness circumferential burns are nonelastic and result in an internal tourniquet effect that compromises distal blood flow when the area involved is an extremity.Circumferential full-thickness torso burns compromise respiratory motion and, when extreme, cardiac return.
NEW QUESTION 37
A normal 3-year-old child is suspected of having meningitis. The doctor has ordered a lumbar puncture. In light of this procedure and developmental characteristics of this age group, which nursing measure is most appropriate?
- A. Emphasize those aspects of the procedure that require cooperation.
- B. Tell the child not to cry or yell.
- C. Tell the child that he will get a “stick” in his back.
- D. Use medical terminology when explaining the procedure to the client.
Answer: A
Explanation:
Section: Questions Set E
Explanation:
(A) The nurse should emphasize what is required to elicit cooperation and help to develop a sense of autonomy. (B) The child may express discomfort verbally and should be encouraged to express his feelings.
(C) Selecting nonthreatening words to explain a procedure will prevent misinterpretation. (D) When explaining the procedure to the parent with the child present, the nurse should use words that the child can understand to avoid misunderstanding.
NEW QUESTION 38
A client is to be discharged from the hospital and is to continue taking warfarin 2.5 mg po bid. Which of the following should be included in her discharge teaching concerning the warfarin therapy?
- A. “Carry a medications alert card with you at all times.”
- B. “You should use a straight-edge razor when shaving your arms and legs.”
- C. “You should take aspirin instead of acetaminophen (Tylenol) for headaches.”
- D. “If you forget to take your morning dose, double the night time dose.”
Answer: A
Explanation:
Section: Questions Set G
Explanation:
(A) Warfarin must always be taken exactly as directed. Clients should be instructed never to skip or double up on their dosage. (B) Aspirin decreases platelet aggregation, which would potentiate the effects of the coumadin. (C) Healthcare providers need to be aware of persons on warfarin therapy prior to the initiation of any diagnostic tests and/or surgery to help prevent bleeding complications. (D) An electric razor should be used to prevent accidental cutting, which can lead to bleeding.
NEW QUESTION 39
A client has consented to have a central venous catheter placed. The best position in which to place the client is the Trendelenburg position. The reason is that the Trendelenburg position:
- A. Allows the physician to visualize the subclavian vein
- B. Makes the procedure more comfortable for the client
- C. Reduces the possibility of air embolism
- D. Reduces the possibility of hematoma formation
Answer: C
Explanation:
Section: Questions Set C
Explanation:
(A) The subclavian vein is not visible during central line insertion regardless of the client’s position. (B) The Trendelenburg position reduces the possibility of air embolism because it places slight positive pressure on the central veins. It also distends the veins, and distention facilitates insertion. (C) This response is untrue; it has no effect on hematoma formation. (D) This position is not necessarily more comfortable for the client, and many clients, especially those who may be short of breath, may find the position uncomfortable and difficult to maintain.
NEW QUESTION 40
……
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