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Questions 158

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Question 1 of 5

Prior to administering digoxin to a client with congestive heart failure, the nurse needs to assess:

Correct Answer: D

Rationale: 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.

Question 2 of 5

A client with a history of a heart transplant is receiving Cyclosporine (Sandimmune). The nurse should monitor the client for:

Correct Answer: A

Rationale: Cyclosporine suppresses immunity, increasing infection risk, requiring vigilant monitoring. Hypotension, hyperkalemia, and weight loss are less common.

Question 3 of 5

A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow. Appropriate nursing actions to help control hyperventilating include:

Correct Answer: C

Rationale: An adult diazepam dosage for treatment of anxiety is 2-10 mg PO 2-4 times daily. The order as written would place a client at risk for overdose. A high room temperature could increase hyperventilating episodes by stimulating the respiratory system. Breath holding and breathing into a paper bag may be useful in controlling hyperventilation. Both measures increase CO2 retention. Distraction will not prevent or control hyperventilation caused by anxiety or fear.

Question 4 of 5

The client is diagnosed with glaucoma. Which medication is most likely to be prescribed?

Correct Answer: A

Rationale: Timolol, a beta-blocker, is commonly prescribed for glaucoma to reduce intraocular pressure by decreasing aqueous humor production. Atropine increases pressure, pilocarpine is less common, and acetazolamide is used acutely.

Question 5 of 5

A client with a history of atrial flutter is admitted with complaints of dizziness. The nurse should give priority to:

Correct Answer: A

Rationale: Atrial flutter causes rapid heart rates, which can lead to dizziness due to reduced cardiac output, so monitoring heart rate is the priority.

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