A nurse in a clinic is caring for an older adult client.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Digoxin Toxicity: The client’s symptoms (nausea, vomiting, diarrhea, weakness), vital signs (bradycardia), and lab results (high digoxin level, low potassium and magnesium) suggest digoxin toxicity.

Cardiac Monitor: To detect any arrhythmias resulting from digoxin toxicity.

Icterus: To assess liver function, which could be impacted in severe toxicity.

Electrolytes: Imbalances in potassium and magnesium can worsen digoxin toxicity and need to be corrected.

Fever: The fever might indicate an infection or inflammatory process, which can affect treatment and recovery.

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Correct Answer is A

Explanation

A. Irregular pulsations are expected with PVCs because they cause occasional early beats that disrupt the regular rhythm of the pulse.

B. Bounding pulsations are not specific to PVCs and are more indicative of conditions like high cardiac output states.

C. Tachycardia is not a direct finding associated with PVCs; PVCs are more about irregular beats rather than a consistently high heart rate.

D. Bradycardia is not typically associated with PVCs; PVCs are characterized by irregular beats but not necessarily a slow heart rate.

A. Side-lying B. Supine C. High-Fowler's D. Leaning forward

Correct Answer is C

Explanation

A. The side-lying position is not appropriate for paracentesis because it does not allow optimal access to the abdomen and can make fluid removal more difficult.

B. The supine position is also not suitable for paracentesis, as it may not allow for proper drainage and can increase the risk of respiratory compromise, especially in clients with large volumes of ascitic fluid.

C. High-Fowler’s position is correct because it helps pool the ascitic fluid in the lower abdomen, making it easier to access and drain during the procedure. This position also helps improve breathing by relieving pressure on the diaphragm caused by the ascites.

D. The leaning forward position is not appropriate for paracentesis, as it can be uncomfortable and does not provide optimal access to the abdominal cavity for fluid removal.

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Naxlex Comprehensive Predictor Exams

A nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client reports feeling lightheaded. If the client is having PVCs, which of the following findings should the nurse expect when auscultating the client's apical pulse?

Correct Answer is A

Explanation

A nurse is preparing a client who is scheduled to undergo a paracentesis. Into which of the following positions should the nurse assist the client for this procedure?

Correct Answer is C

Explanation

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