A nurse is preparing to administer digoxin orally to a client. Identify the sequence of steps the nurse should take (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)

Remove the medication from the dispensing system.

Compare the client’s wristband to the medication administration record.

Document administration of the medication.

Open the medication package.

Obtain the client’s apical heart rate.

Answer and Explanation

The Correct Answer is E, A, B, D, C

Before administering digoxin, the nurse should check the patient's apical heart rate. If the heart rate is below 60 beats per minute for an adult, or below the prescribed limit for a child, the nurse should hold the medication and notify the healthcare provider. This is the first step because the nurse needs to have the medication in hand before proceeding with the other steps. This step is crucial to ensure that the right medication is being given to the right patient. It's a part of the "five rights" of medication administration: right patient, right medication, right dose, right route, and right time. Once the nurse has confirmed the patient's identity and heart rate, the next step is to open the medication package. After administering the medication, the nurse should document it in the patient's medical record. This is important for maintaining an accurate record of the patient's medication history.

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Correct Answer is D

Explanation

D. Pins or wires are often inserted into the bone to apply traction, and these insertion sites provide a potential route for infection. The nurse should assess the pin sites regularly for signs of infection, such as redness, swelling, warmth, or drainage. Early detection and treatment of pin site infections help prevent the spread of infection and promote healing.
A. Administer pain medication at designated intervals around the clock:
While pain management is important for a client with a fracture, the primary intervention for skeletal traction is not necessarily related to pain medication administration.
B. Assessing pulses proximal to the fracture site is important for monitoring circulation and detecting any signs of impaired perfusion. However, this intervention is more relevant to vascular assessment and may not be directly related to skeletal traction.
C. Skeletal traction is typically maintained continuously to provide consistent traction and promote proper alignment of the fractured bone. Removing traction every shift would disrupt the therapeutic effect and delay healing.

A. A 12-year-old child with history of asthma who is wheezing and complaining of shortness of breath. B. A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakiness C. A 10-year-old child with bleeding lacerations on both knees after falling on the playground D. A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode.

Correct Answer is A,B,C,D

Explanation

A 12-year-old child with history of asthma who is wheezing and complaining of shortness of breath.

This client has the highest priority, as he or she may be experiencing an acute asthma atack that can compromise the airway and oxygenation. The PN should assess the client's respiratory status, administer bronchodilators, and monitor for improvement or deterioration.

A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakiness.

This client has the second highest priority, as he or she may be experiencing hypoglycemia, which is a low blood glucose level that can cause neurologic symptoms such as confusion, seizures, or coma. The PN should check the client's blood glucose level, provide a source of glucose, and monitor for recovery or complications.

A 10-year-old child with bleeding lacerations on both knees after falling on the playground.

This client has the third highest priority, as he or she may have a risk of infection or blood loss from the wounds. The PN should clean and dress the lacerations, apply pressure if needed, and check for signs of infection or inﬂammation.

A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode.

This client has the lowest priority, as he or she does not have a life-threatening or urgent condition, but a psychosocial or emotional issue. The PN should provide comfort and reassurance to the child, change his or her clothes, and explore the possible causes of the incontinence.

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A nurse is preparing to administer digoxin orally to a client. Identify the sequence of steps the nurse should take (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?

Correct Answer is D

Explanation

Correct Answer is A,B,C,D

Explanation

A client with a renal calculus reports severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?

An adult client who was recently diagnosed with glaucoma tells the nurse, "It feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?

Patient Data Exhibits After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

Which dietary instruction is most important for the nurse to explain to a client who has had gastric bypass surgery?

Patient’s Data Exhibits Select the 3 dietary choices that are not part of the recommended diet gout.

The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?

A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?