Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is providing discharge teaching for a client who has heart failure and is to start therapy with digoxin. Which of the following statements by the client indicates an understanding of the teaching?
A. "I will take this medication with fiber to prevent constipation."
While constipation is a potential side effect of digoxin, taking it with fiber is not a recommended method for preventing constipation.
B. "I will notify my provider if I experience muscle weakness."
Muscle weakness can be a sign of digoxin toxicity, and it is essential for the client to notify their healthcare provider if they experience this symptom. Muscle weakness is a potential adverse effect of digoxin, especially if the medication level in the blood becomes too high.
C. "I will increase my dose if my vision becomes blurred."
Blurred vision can be a sign of digoxin toxicity, and the client should not increase their dose if they experience this symptom. Instead, they should promptly notify their healthcare provider to assess for toxicity and adjust the medication regimen as needed.
D. "I will take my digoxin if my pulse is less than 50 beats per minute."
Digoxin is a medication that can slow the heart rate, and a pulse rate less than 60 beats per minute is considered bradycardia. If the client's pulse is less than 60 beats per minute, they should hold the digoxin and promptly notify their healthcare provider.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Adult Medical Surgical 2023 Proctored Exam. Take the full exam now
Full Explanation
B. Muscle weakness can be a sign of digoxin toxicity, and it is essential for the client to notify their healthcare provider if they experience this symptom. Muscle weakness is a potential adverse effect of digoxin, especially if the medication level in the blood becomes too high.
A. While constipation is a potential side effect of digoxin, taking it with fiber is not a recommended method for preventing constipation.
C. Blurred vision can be a sign of digoxin toxicity, and the client should not increase their dose if they experience this symptom. Instead, they should promptly notify their healthcare provider to assess for toxicity and adjust the medication regimen as needed.
D. Digoxin is a medication that can slow the heart rate, and a pulse rate less than 60 beats per minute is considered bradycardia. If the client's pulse is less than 60 beats per minute, they should hold the digoxin and promptly notify their healthcare provider.
Similar Questions
A nurse is caring for a client who is 3 hr postoperative. Which of the following findings should the nurse understand is a manifestation of bleeding?
A. Hypertension
Typically, bleeding would cause a decrease in blood pressure rather than hypertension. High blood pressure could indicate other issues like pain or anxiety
B. 2+ edema
Edema is not typically a direct manifestation of bleeding. It could indicate fluid overload, a common complication post-surgery, but not necessarily indicative of bleeding.
C. Crackles in lungs
Crackles in lungs could suggest fluid overload or pulmonary edema but not related to bleeding.
D. Tachycardia
Increased heart rate (tachycardia) is a common manifestation of bleeding. The body compensates for blood loss by increasing the heart rate to maintain blood flow to vital organs
Full Explanation
D. Increased heart rate (tachycardia) is a common manifestation of bleeding. The body compensates for blood loss by increasing the heart rate to maintain blood flow to vital organs
A. Typically, bleeding would cause a decrease in blood pressure rather than hypertension. High blood pressure could indicate other issues like pain or anxiety
B. Edema is not typically a direct manifestation of bleeding. It could indicate fluid overload, a common complication post-surgery, but not necessarily indicative of bleeding.
C. Crackles in lungs could suggest fluid overload or pulmonary edema but not related to bleeding.
A nurse is caring for an older adult client who reports vaginal dryness and itching. Which of the following responses should the nurse make?
A. "These discomforts should decrease with time."
This response dismisses the client's symptoms without addressing the underlying cause or providing potential solutions.
B. "Women your age experience thickening of the vaginal tissue."
The opposite tends to occur with age – vaginal tissue can become thinner and drier due to decreasing estrogen levels, leading to symptoms like vaginal dryness and itching.
C. "Your symptoms are likely due to decreasing estrogen levels."
It acknowledges the client's symptoms and provides a likely explanation related to hormonal changes associated with aging. It opens the door for further discussion and potential interventions to address the underlying cause.
D. "You should avoid intercourse to prevent injury to your vagina."
While avoiding intercourse may be recommended in certain situations, such as if there is discomfort or pain, it does not address the underlying cause of the symptoms. Additionally, it may not be necessary if appropriate treatments are pursued to alleviate vaginal dryness and itching.
Full Explanation
C. It acknowledges the client's symptoms and provides a likely explanation related to hormonal changes associated with aging. It opens the door for further discussion and potential interventions to address the underlying cause.
A. This response dismisses the client's symptoms without addressing the underlying cause or providing potential solutions.
B. The opposite tends to occur with age – vaginal tissue can become thinner and drier due to decreasing estrogen levels, leading to symptoms like vaginal dryness and itching.
D. While avoiding intercourse may be recommended in certain situations, such as if there is discomfort or pain, it does not address the underlying cause of the symptoms. Additionally, it may not be necessary if appropriate treatments are pursued to alleviate vaginal dryness and itching.
A nurse is performing a fall risk assessment on a client. Which of the following findings indicates the client has an increased fall risk?
A. The client asks for help before ambulating.
This indicates that the client is aware of their limitations and is proactive in seeking assistance, which may actually decrease their fall risk. It demonstrates awareness and caution.
B. The client has a history of urinary incontinence.
Urinary incontinence can increase fall risk due to the need for frequent trips to the bathroom, which may increase the chances of tripping or falling, especially if the client rushes to the bathroom.
C. The client lives with their caregiver.
While having a caregiver present can provide support and assistance, it doesn't necessarily indicate an increased fall risk. In fact, having a caregiver present may decrease the risk of falls by providing supervision and assistance as needed.
D. The client has bronchitis.
Bronchitis itself does not directly contribute to an increased fall risk.
Full Explanation
B. Urinary incontinence can increase fall risk due to the need for frequent trips to the bathroom, which may increase the chances of tripping or falling, especially if the client rushes to the bathroom.
A. This indicates that the client is aware of their limitations and is proactive in seeking assistance, which may actually decrease their fall risk. It demonstrates awareness and caution.
C. While having a caregiver present can provide support and assistance, it doesn't necessarily indicate an increased fall risk. In fact, having a caregiver present may decrease the risk of falls by providing supervision and assistance as needed.
D. Bronchitis itself does not directly contribute to an increased fall risk.