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 B

Explanation

A. Fluids should not be restricted; adequate hydration is necessary to help flush the contrast dye used during the procedure out of the client's system.
B. Performing neurovascular checks with vital signs is essential to monitor for complications such as bleeding, hematoma, or compromised circulation to the extremity.
C. The client should avoid range-of-motion exercises to the lower extremities immediately following the procedure to prevent disruption of the femoral artery site.
D. The client should remain on bed rest for several hours following the procedure to reduce the risk of bleeding at the catheter insertion site.

A. Blockage of the ET tube by the client's tongue B. Movement of the ET tube into the right main bronchus C. Infection of the vocal cords D. Passage of the ET tube into the esophagus

Correct Answer is B

Explanation

A. Blockage of the ET tube by the client's tongue would not typically result in asymmetric chest wall expansion.
B. If the ET tube has moved into the right main bronchus, it will cause more air to enter the right lung and less to the left, leading to decreased left-sided chest wall expansion.
C. Infection of the vocal cords is not related to the absence of chest wall expansion.
D. Passage of the ET tube into the esophagus would lead to the absence of breath sounds in both lungs, not just the left side.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client following a cardiac catheterization accessed through his femoral artery. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

A nurse in the PACU is assessing a client who has an endotracheal (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?

Correct Answer is B

Explanation

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