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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A gastric residual volume of 250 mL following 2 hours of infusion may indicate potential intolerance to the feeding, but it is not necessarily an immediate emergency unless it exceeds the facility’s threshold for residuals.
B. The client lying in a supine position poses a significant risk for aspiration, especially following a laryngectomy, where airway protection is compromised. Immediate intervention is necessary to reposition the client and reduce the risk of aspiration pneumonia.
C. While the infusion pump being off is concerning, it may not require immediate intervention as long as the nurse is aware and can address it promptly.
D. Not dating the enteral feeding bag and tubing is important for infection control; however, it does not require immediate intervention compared to the risk posed by a supine position.
Correct Answer is A
Explanation
A.
A. Justice refers to fairness and equity in the distribution of resources and the treatment of
individuals. By spending an equal amount of time with each client regardless of their background or actions, the nurse is demonstrating the principle of justice.
B. Autonomy refers to respecting the right of individuals to make their own decisions about their healthcare. While important, it does not directly relate to the nurse's equal allocation of time.
C. Nonmaleficence refers to the duty to do no harm. While relevant to nursing care, it does not directly apply to the equal distribution of time among clients.
D. Veracity refers to truthfulness and honesty in communication. While important, it does not directly relate to the allocation of time among clients.
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