br>History and Physical

BP 100/60 mm Hg Pulse 52/min
Respiratory rate 20/min

Temperature 37.2" C (99.0° F)

A nurse is caring for an adolescent who is receiving treatment for heart failure. Based on the

client's chart findings, which of the following actions should the nurse plan to take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Administer furosemide.

Withhold digoxin.

Withhold spironolactone.

Administer ferrous sulfate.

Answer and Explanation

The Correct Answer is B

A. Administering furosemide may also be appropriate for managing heart failure symptoms, but the priority action based on the client's condition is to withhold digoxin.

B. The client's vital signs indicate bradycardia (pulse 52/min), which is a common adverse effect of digoxin, especially in the setting of heart failure. Withholding digoxin is necessary to prevent further exacerbation of bradycardia and potential toxicity.

C. Withholding spironolactone may be considered if there are concerns about electrolyte imbalances, but it is not the priority action in this scenario.

D. Administering ferrous sulfate is not indicated based on the client's chart findings; there is no indication of anemia or iron deficiency.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Adjusting the straps on the harness once per week is not recommended. The straps should only be adjusted by a healthcare provider to ensure proper fit and alignment, as incorrect adjustments can compromise the effectiveness of the treatment.

B. Using ultra-thin diapers applied over the straps is incorrect. Diapers should be placed under the harness to prevent soiling and maintain the harness's effectiveness. Placing diapers over the straps can interfere with proper positioning.

C. Maintaining the child in a prone position while the harness is in place is not necessary. The Pavlik harness is designed to keep the hips in a flexed and abducted position, and the infant can remain in various positions that are comfortable and safe.

D. Gently massaging the skin under the straps once per day is correct. This helps prevent skin irritation and promotes circulation. Guardians should also check for redness or irritation and ensure the harness fits properly to avoid pressure injuries.

A. The client is taking an antidepressant. B. The client has a history of a seizure disorder. C. The client takes aspirin daily. D. The client has a history of rheumatoid arthritis.

Correct Answer is C

Explanation

A. There is no known significant interaction between garlic supplements and antidepressants.

B. There is no evidence to suggest that garlic supplements are contraindicated for individuals with a history of seizure disorders. Garlic is not known to exacerbate seizure activity or interact with anticonvulsant medications.
C. Garlic has antiplatelet properties, which can increase the risk of bleeding, especially when combined with other blood-thinning agents like aspirin. Clients who take aspirin daily are at an increased risk of bleeding complications if they also take garlic supplements. This makes it a contraindication in such cases.
D. There are no known contraindications specifically related to rheumatoid arthritis and garlic supplements.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching the guardian of an infant who has developmental dysplasia of the hip about a Pavlik harness. Which of the following Instructions should the nurse include?

Correct Answer is D

Explanation

A nurse is reviewing the medical history of a client who is taking a garlic supplement. The nurse should identify that which of the following findings is a contraindication for taking this supplement?

Correct Answer is C

Explanation

A nurse is observing a newly licensed nurse irrigate a client's wound. Which of the following actions should the nurse identify as an indication that the newly licensed nurse understands wound irrigation?

A home health nurse is teaching a guardian about administering tube feedings to their 3-month-old infant. Which of the following information should the nurse include in the teaching?

A nurse is preparing to administer eye drops to a client. Which of the following nursing actions is appropriate?

A nurse is assessing a client who has a magnesium level of 4.4 mEq/L. Which of the following findings should the nurse expect?

A nurse is caring for a client who reports chest pain. Which of the following laboratory findings indicates myocardial damage?

A nurse is preparing to insert an indwelling urinary catheter for a female client. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A home health nurse is reviewing treatment goals with a client who has diabetes mellitus.The nurse should evaluate which of the following laboratory tests to determine effective long- term management of blood glucose levels?

A nurse from the State Health Department is instructing a group of nurses regarding reportable infections. Which of the following infections should the nurse report to the Centers for Disease Control and Prevention?