Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?
A. Request a dietitian consult.
Request a dietitian consult is wrong because it is not the priority action and it does not address the possible cause of the client's symptoms. A dietitian consult may be helpful to provide nutritional education and guidance, but only after ruling out or treating digoxin toxicity.
B. Suggest that the client rests before eating the meal.
Suggest that the client rests before eating the meal is wrong because it is not the priority action and it may delay the diagnosis and treatment of digoxin toxicity. The nurse should not assume that the client's symptoms are due to fatigue or lack of appetite, but rather investigate for any underlying problems.
C. Request an order for an antiemetic.
Request an order for an antiemetic is wrong because it is not the priority action and it may mask the symptoms of digoxin toxicity. The nurse should not administer any medications that could interact with digoxin or worsen its effects, but rather notify the provider and follow the protocol for digoxin toxicity management.
D. Check the client's vital signs.
The nurse should check the client's vital signs first because nausea and weakness are signs of digoxin toxicity, which can also cause bradycardia, hypotension, and arrhythmias. The nurse should also assess the client's serum digoxin level, potassium level, and electrocardiogram.
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Full Explanation
The nurse should check the client's vital signs first because nausea and weakness are signs of digoxin toxicity, which can also cause bradycardia, hypotension, and arrhythmias. The nurse should also assess the client's serum digoxin level, potassium level, and electrocardiogram.
Request a dietitian consult is wrong because it is not the priority action and it does not address the possible cause of the client's symptoms. A dietitian consult may be helpful to provide nutritional education and guidance, but only after ruling out or treating digoxin toxicity.
Suggest that the client rests before eating the meal is wrong because it is not the priority action and it may delay the diagnosis and treatment of digoxin toxicity. The nurse should not assume that the client's symptoms are due to fatigue or lack of appetite, but rather investigate for any underlying problems.
Request an order for an antiemetic is wrong because it is not the priority action and it may mask the symptoms of digoxin toxicity. The nurse should not administer any medications that could interact with digoxin or worsen its effects, but rather notify the provider and follow the protocol for digoxin toxicity management.
Similar Questions
A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?
A. Thick, deformed toenails
Thick, deformed toenails are more likely to be seen in clients who have fungal infections or peripheral arterial disease, not chronic venous insufficiency.
B. Edema
Edema is a common finding in clients who have chronic venous insufficiency, due to the impaired venous return and increased capillary pressure. The edema is usually worse at the end of the day and improves with elevation.
C. Dependent rubor
Dependent rubor is a sign of peripheral arterial disease, not chronic venous insufficiency. It is a reddish color of the lower extremities that occurs when they are lowered and disappears when they are elevated.
D. Hair loss
Hair loss is another sign of peripheral arterial disease, not chronic venous insufficiency. It is caused by the reduced blood supply to the hair follicles.
Full Explanation
Edema is a common finding in clients who have chronic venous insufficiency, due to the impaired venous return and increased capillary pressure. The edema is usually worse at the end of the day and improves with elevation.
a. Thick, deformed toenails are more likely to be seen in clients who have fungal infections or peripheral arterial disease, not chronic venous insufficiency.
c. Dependent rubor is a sign of peripheral arterial disease, not chronic venous insufficiency. It is a reddish color of the lower extremities that occurs when they are lowered and disappears when they are elevated.
d. Hair loss is another sign of peripheral arterial disease, not chronic venous insufficiency. It is caused by the reduced blood supply to the hair follicles.
A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?
A. Peripheral edema
Peripheral edema is a common finding in clients who have right-sided heart failure, due to the increased venous pressure and fluid retention. The edema is usually symmetrical and affects the lower extremities, abdomen, and sometimes the face.
B. Chest pain
Chest pain is not a typical finding of right-sided heart failure, unless there is an underlying cause such as coronary artery disease or pulmonary hypertension.
C. Heart murmur
Heart murmur is not a specific finding of right-sided heart failure, but it may indicate a valvular disorder that can contribute to or result from heart failure.
D. Crackles in lungs
Crackles in lungs are more likely to be seen in clients who have left-sided heart failure, due to the pulmonary congestion and impaired gas exchange.
A nurse is caring for a client who has peripheral arterial disease (PAD). Which of the following symptoms should the nurse expect to find in the early stage of the disease?
A. Dependent rubor
Dependent rubor is a sign of PAD in the advanced stage, due to the impaired vasodilation and reactive hyperemia. It is a reddish color of the lower extremities that occurs when they are lowered and disappears when they are elevated.
B. Intermitent claudication
Intermittent claudication is a characteristic symptom of PAD in the early stage, due to the reduced blood flow to the muscles during exercise. It is a cramping pain in the legs that occurs with walking and is relieved by rest.
C. Foot ulcers
Foot ulcers are a complication of PAD in the late stage, due to the poor wound healing and tissue necrosis. They are usually located on the toes, heels, or pressure points.
D. Rest pain
Rest pain is another sign of PAD in the late stage, due to the severe ischemia and nerve damage. It is a persistent pain in the feet or toes that occurs at night and is not relieved by rest.
Full Explanation
The correct answer is B
Choice B reason: Intermittent claudication
Intermittent claudication is a characteristic symptom of PAD in the early stage, due to the reduced blood flow to the muscles during exercise. It is a cramping pain in the legs that occurs with walking and is relieved by rest.
Choice A reason: Dependent rubor is a sign of PAD in the advanced stage, due to the impaired vasodilation and reactive hyperemia. It is a reddish color of the lower extremities that occurs when they are lowered and disappears when they are elevated.
Choice C reason: Foot ulcers are a complication of PAD in the late stage, due to the poor wound healing and tissue necrosis. They are usually located on the toes, heels, or pressure points.
Choice D reason: Rest pain is another sign of PAD in the late stage, due to the severe ischemia and nerve damage. It is a persistent pain in the feet or toes that occurs at night and is not relieved by rest.
