A patient with a history of heart failure is prescribed digoxin. Which assessment finding indicates a potential adverse effect of digoxin therapy?

Correct Answer: D

Rationale: Confusion is a potential adverse effect of digoxin therapy. Digoxin toxicity can manifest as various central nervous system symptoms, including confusion, delirium, and disorientation. It is important to monitor for signs of digoxin toxicity in patients taking this medication, especially those with a history of heart failure or renal impairment. Other common signs of digoxin toxicity may include visual disturbances (like halos around lights), gastrointestinal symptoms (like nausea and vomiting), and cardiac arrhythmias. Monitoring serum digoxin levels can help guide therapy and identify toxicity early.

Correct Answer: D

Rationale: In a 55-year-old postmenopausal woman presenting with vaginal bleeding and a healthy cervix on examination, the most likely cause would be a cervical polyp. Cervical polyps are benign growths that can occur on the cervix and are often asymptomatic but can occasionally cause postmenopausal bleeding. Their appearance on examination would typically be a non-malignant finding with no cervical motion tenderness. Cervical cancer, endometrial cancer, and vaginal cancer would typically present with different examination findings and risk factors.

Correct Answer: D

Rationale: If a nurse notices a discrepancy between the surgical count and the number of instruments on the sterile field during surgery, it is crucial to inform the surgical team immediately and initiate a thorough search. Patient safety is of utmost importance, and any missing instruments could potentially pose a risk to the patient. By informing the team and conducting a thorough search, the missing instrument can be located promptly to ensure it is not inadvertently left inside the patient's body. Continuing with the procedure or ignoring the discrepancy without further investigation could lead to serious consequences for the patient's well-being. It is always better to address any discrepancies or concerns during surgery proactively to maintain a high standard of patient care and safety.

Correct Answer: A

Rationale: Pneumothorax is a condition characterized by the presence of air in the pleural space surrounding the lungs, which can lead to lung collapse. The nurse's assessment findings in a patient with pneumothorax are typically as follows:

Correct Answer: C

Rationale: For managing a conscious patient with a dislocated shoulder, the appropriate action is to provide analgesia to help manage the pain and discomfort associated with the dislocation. Applying ice packs to the affected shoulder can also help reduce swelling and provide some relief. It is important to refrain from attempting to reduce the dislocation by pulling on the affected arm, as this can cause further damage and worsen the injury. Applying a splint to immobilize the arm in the dislocated position is also not recommended, as this can lead to complications and hinder the reduction process. Administering intravenous fluids to prevent dehydration is not directly related to managing a dislocated shoulder in a conscious patient.

Correct Answer: A

Rationale: The most important intervention for managing ventilator-associated pneumonia (VAP) caused by methicillin-resistant Staphylococcus aureus (MRSA) in a patient undergoing mechanical ventilation in the ICU is to start appropriate antimicrobial therapy targeting MRSA. Vancomycin or linezolid are commonly used antibiotics for MRSA infections. These medications are effective against MRSA and can help in treating the infection and preventing further complications. It is crucial to initiate antimicrobial therapy promptly once the diagnosis of VAP caused by MRSA is suspected or confirmed to improve patient outcomes. Other interventions such as bronchoalveolar lavage for diagnostic purposes, contact precautions, or antifungal therapy may be relevant but the priority is to start effective antibiotic therapy to target the specific pathogen causing the infection.

Correct Answer: C

Rationale: The described presentation of a yellowish-white spot on the cornea with a ring of inflammation, along with branching, filamentous opacities extending from the corneal lesion, is characteristic of fungal keratitis. Fungal keratitis typically presents with these specific features on clinical examination.

Correct Answer: B

Rationale: The laboratory test used to monitor the therapeutic effect of warfarin therapy is the International Normalized Ratio (INR). Warfarin is a commonly prescribed anticoagulant medication that works by inhibiting the action of vitamin K-dependent clotting factors. Maintaining the INR within the target range specific to the indication for anticoagulation (e.g., DVT prevention or treatment) is essential to balance the risk of bleeding and clotting.

Correct Answer: C

Rationale: The appropriate ratio of chest compressions to rescue breaths for adult CPR is 30 compressions to 2 breaths. This means that after every 30 chest compressions, two rescue breaths should be given. This ratio helps in maintaining oxygen circulation in the body while also ensuring that the heart is being effectively pumped to circulate blood. The emphasis on chest compressions is critical in maintaining blood flow to vital organs during cardiac arrest, while the rescue breaths help in providing oxygen to the patient's lungs. This ratio is recommended by organizations like the American Heart Association for performing high-quality adult CPR.