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Questions 158

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Extract:


Question 1 of 5

A six-month-old is receiving Lanoxin elixir (digoxin) following the repair of a VSD. Which finding should be reported to the physician?

Correct Answer: C

Rationale: A heart rate of 80 beats per minute in a six-month-old is low (normal range: 100-160 bpm) and may indicate digoxin toxicity or worsening cardiac function post-VSD repair. The other findings are within normal limits for an infant.

Question 2 of 5

A client with a history of peptic ulcer disease is admitted with complaints of hematemesis. The nurse should give priority to:

Correct Answer: B

Rationale: Hematemesis indicates possible gastrointestinal bleeding, so monitoring vital signs is critical to assess for hypovolemia and shock.

Question 3 of 5

Which action by the home health nurse indicates a knowledge of the needs of an elderly client?

Correct Answer: D

Rationale: Fall prevention is a critical need for elderly clients due to risks of injury from reduced mobility or balance. Hospice teaching is premature, high-pitched speech may not aid hearing, and fluid restriction can cause dehydration.

Question 4 of 5

The nurse is caring for a client with a history of rheumatoid arthritis who is receiving Methotrexate (Rheumatrex). The nurse should monitor the client for:

Correct Answer: A

Rationale: Methotrexate can cause hepatotoxicity, requiring monitoring of liver enzymes. Hypotension, hyperglycemia, and thrombocytosis are not common side effects.

Question 5 of 5

A client with a history of chronic kidney disease is admitted with complaints of shortness of breath. The nurse should give priority to:

Correct Answer: A

Rationale: Shortness of breath in chronic kidney disease may indicate fluid overload, so administering diuretics is the priority.

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