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Questions 158

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Extract:


Question 1 of 5

The client is prescribed digoxin (Lanoxin) for heart failure. Which instruction should the nurse include in the teaching plan?

Correct Answer: B

Rationale: Digoxin toxicity is increased with bradycardia, so a pulse below 60 beats per minute should be reported. It can be taken with or without food, potassium monitoring is important but not increasing, and extra doses are dangerous.

Question 2 of 5

The nurse is caring for a client with a history of a retinal detachment who is scheduled for a scleral buckling procedure. The nurse should:

Correct Answer: B

Rationale: Eye drops (e.g., mydriatics) are often ordered pre-scleral buckling to dilate the pupil or reduce pressure. Flat positioning, fluid restriction, and breathing exercises are not standard.

Question 3 of 5

The nurse is assisting in the care of a patient who is two days post-operative from a hemorrhoidectomy. The nurse would be correct in instructing the patient to:

Correct Answer: D

Rationale: Sitz baths after bowel movements promote healing and relieve pain post-hemorrhoidectomy by keeping the area clean and reducing inflammation. High-fiber diets are encouraged, ice packs are typically used earlier, and laxatives may be prescribed but are not the priority.

Question 4 of 5

Which of the following is not a step in primary assessment of a client presenting to the emergency department after being involved in a motor vehicle accident?

Correct Answer: B

Rationale: Primary assessment in trauma follows the ABCDE approach (Airway Breathing Circulation Disability Exposure). Obtaining vital signs is part of the secondary assessment not the primary survey which focuses on immediate life threats like airway bleeding and responsiveness.

Question 5 of 5

An obstetrical client with diabetes has an amniocentesis at 28 weeks gestation. Which test indicates the degree of fetal lung maturity?

Correct Answer: D

Rationale: The lecithin-sphingomyelin (L/S) ratio measures fetal lung maturity by assessing surfactant production, critical for preventing respiratory distress syndrome in preterm infants.

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