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Questions 158

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Question 1 of 5

Before administering a client's morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:

Correct Answer: C

Rationale: A pulse rate below 60 bpm indicates bradycardia, a contraindication for digoxin due to the risk of worsening heart block. The nurse should withhold the dose and notify the physician.

Question 2 of 5

A 5-year-old child was recently diagnosed as having acute lymphoid leukemia. She is hospitalized for additional tests and to begin a course of chemotherapy designed to induce a remission. She is scheduled to have a bone marrow aspiration tomorrow. She has had a bone marrow test previously and is apprehensive about having another. Which of the following interventions will be most effective in relieving her anxiety?

Correct Answer: A

Rationale: Providing a detailed explanation of the procedure helps reduce anxiety by preparing the child for what to expect, addressing her previous experience.

Question 3 of 5

A client with a history of a stroke is being taught to use a cane. The nurse should teach the client to:

Correct Answer: C

Rationale: The cane should be used on the weak side to support the affected leg, improving balance and gait post-stroke. Holding it in the strong hand or advancing with the strong leg is incorrect.

Question 4 of 5

The nurse is caring for a client with a history of diverticulitis. Which meal selection indicates that the client understands the dietary teaching?

Correct Answer: B

Rationale: Clients with diverticulitis should follow a low-residue diet during flare-ups to reduce bowel irritation. Baked chicken, rice, and an apple are low in fiber and suitable. The other options contain high-fiber or irritating foods (e.g., spinach, whole wheat, garlic).

Question 5 of 5

The nurse is assessing a client with suspected anaphylactic shock. Which intervention is the priority?

Correct Answer: A

Rationale: Epinephrine is the priority in anaphylactic shock to reverse bronchoconstriction and hypotension. IV fluids and oxygen are secondary, and Trendelenburg is not recommended.

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