The nurse is preparing to administer a dose of digoxin (Lanoxin) to a child in heart failure (HF). Which is a beneficial effect of administering digoxin (Lanoxin)?

Correct Answer: A

Rationale: Digoxin is a medication commonly used in the treatment of heart failure (HF) because of its positive inotropic effect, which means it strengthens the heart muscle. While digoxin does not directly decrease edema, its ability to increase the strength of the heart muscle allows the heart to pump more effectively. When the heart is pumping blood more efficiently, it can help reduce fluid accumulation in the body, including edema.

Correct Answer: B

Rationale: A nurse measures the intake and output and recommends a daily fluid intake of approximately 3000 to 4000 mL for a client with pyelonephritis primarily to help flush out the infectious microorganisms from the urinary tract. Pyelonephritis is a bacterial infection of the kidneys and urinary tract, and increasing fluid intake can help dilute the urine and increase urine output, which may help wash out and eliminate the infectious microorganisms causing the infection. Adequate hydration also helps the kidneys function optimally in eliminating waste and toxins from the body. Therefore, maintaining a high fluid intake is crucial in the management of pyelonephritis to support the body's natural defense mechanisms and aid in recovery.

Correct Answer: C

Rationale: The essential assessment for a client undergoing urinary diversion is the client's knowledge about the effects of the surgery on his nervous control. Urinary diversion is a surgical procedure that involves redirecting urine flow from the bladder to a new exit point in the body due to bladder cancer, birth defects, or other medical conditions. Understanding the effects of the surgery on nervous control is crucial as it can impact the client's ability to control urination and bowel movements post-surgery. Educating the client about these effects will help in managing expectations and in planning for any necessary adjustments to their lifestyle and daily routine. It is important for the nurse to assess the client's level of understanding and provide appropriate education and support regarding nervous control changes that may result from the procedure.

Correct Answer: A

Rationale: The patient's symptoms of tingling in the fingers, positive Trousseau's and Chvostek's signs, and feeling depressed are suggestive of hypocalcemia, which is commonly associated with low serum calcium levels. In this case, the most likely serum calcium value would be below the normal range, which is around 8.5-10.5 mg/dl. Among the given choices, an extremely low calcium value of 5mg/dl (Choice D) would be more consistent with severe hypocalcemia presenting with tetany and other neuromuscular symptoms rather than depression and mild symptoms. On the other hand, a high calcium level of 11mg/dl (Choice A) would indicate hypercalcemia, which can lead to neuropsychiatric symptoms like depression, as seen in this patient's presentation. Therefore, Choice A (11mg/dl) is the most likely serum calcium value for

Correct Answer: C

Rationale: The dietary practice that will help a client reduce the dietary intake of sodium is avoiding the use of carbonated beverages. Carbonated beverages, such as sodas, contain high amounts of sodium that can contribute to increased sodium intake. By avoiding carbonated beverages, the client can effectively reduce their overall sodium consumption. Increasing the use of dairy products, using artificial sweeteners in coffee, and using catsup for cooking and flavoring food do not specifically address the reduction of sodium intake in the same way that avoiding carbonated beverages does.