An elderly client with heart failure comet to the emergency room because of nausea, vomiting, and anorexia. Based on the client’s signs and symptoms, which data from the medical history has the most significance when planning this client’s care?

A coronary artery bypass procedure was performed in 1995.

Suﬀered with depression following death of spouse in 1999.

Digoxin and furosemide daily since 1996.

A Colonoscopy was performed for routine screening six months ago.

Answer and Explanation

The Correct Answer is C

Digoxin is a medication commonly used to treat heart failure by strengthening the heart's contractions and slowing down the heart rate. However, it can also cause nausea, vomiting, and loss of appetite, especially when levels in the body are too high. Furosemide is a diuretic medication that helps to remove excess ﬂuid from the body, which is often necessary in heart failure. However, it can also cause electrolyte imbalances, such as low potassium levels, which can contribute to nausea and vomiting.

Therefore, in a client with heart failure who is experiencing these symptoms, it is important to assess their medication regimen, including dosages and serum levels, to ensure that they are not experiencing medication side eﬀects or toxicity.

Adjustments may need to be made to the client's medication regimen to manage symptoms eﬀectively and prevent further complications. Options (a), (b), and (d) do not have as direct a correlation to the current symptoms and would not have the same level of significance when planning care for this client.

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Correct Answer is C

Explanation

Restless legs syndrome is a condition that causes an uncomfortable sensation in the legs and an uncontrollable urge to move them. Melatonin is a natural hormone that helps regulate the sleep-wake cycle and can be used as a sleep aid. Therefore, when evaluating the eﬀectiveness of melatonin in an older adult client with restless legs syndrome, the nurse should assess the client's sleep patterns to determine if the herb is improving their ability to fall and stay asleep.

Assessing anxiety level (a) may be useful in other contexts, but it is not directly relevant to evaluating the eﬀectiveness of melatonin for restless legs syndrome. Observing for peripheral edema (b) and palpating pedal pulse volume (d) are important assessments in clients with peripheral vascular disease or other circulatory disorders, but they are not directly related to restless legs syndrome or the use of melatonin.

A. Consult a pharmacist about the scheduling of the dose one hour after the client eats. B. Assign unlicensed assistive personnel (UAP) to bring the client a glass of low-fat milk. C. Withhold the medication until the client’s breakfast tray is available on the unit. D. Instruct the client that it is necessary to take nothing but water with the medication.

Correct Answer is D

Explanation

Risedronate should be taken with plain water only. It should be taken on an empty stomach, at least 30 minutes before eating or drinking anything other than plain water. Taking risedronate with milk or other beverages can interfere with its absorption and reduce its eﬀectiveness.

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An elderly client with heart failure comet to the emergency room because of nausea, vomiting, and anorexia. Based on the client’s signs and symptoms, which data from the medical history has the most significance when planning this client’s care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client with restless legs syndrome begins taking melatonin at bedtime. When evaluating the eﬀectiveness of the herb which client assessment should the nurse complete?

Correct Answer is C

Explanation

The nurse administers risedronate to a client with osteoporosis at 07:00. The client asks for a glass of milk to drink with the medication. Which action should the nurse take?

Correct Answer is D

Explanation

A client with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?

A client with psychosis who is receiving an antipsychotic medication is continuously rubbing the back of the neck. Which nursing intervention is best for the nurse to implement?

An elderly client with heart failure comet to the emergency room because of nausea, vomiting, and anorexia. Based on the client’s signs and symptoms, which data from the medical history has the most significance when planning this client’s care?

A client who receives multiple antihypertensive multiple medications experiences syncope due to a drop in blood pressure to 70/40 mm Hg. Which is the rationale for the nurse’s decision to hold the client’s scheduled antihypertensive medications?

A client with muscle spasticity receives a prescription for baclofen. Which information provided by the client requires additional instruction by the nurse?

A client with chemotherapy induced nausea receives a prescription for metoclopramide. Which adverse eﬀect is most important for the nurse to report?

A female client with a history of peptic ulcer disease receives a prescription for misoprostol. Which information provided by the client indicates to the nurse a need for further teaching?