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: An INR of 1.1 is within the normal range, indicating normal blood clotting ability, which is essential for wound healing. A normal INR does not pose a risk for delayed wound healing.
- B: Hyperemesis can lead to dehydration and malnutrition, both of which are detrimental to wound healing. Dehydration reduces blood volume and flow, impairing the delivery of oxygen and nutrients to the wound site, while malnutrition can weaken the immune response and the formation of new tissue.
- C: An HbA1C level of 5.6% is at the high end of the normal range and does not typically indicate diabetes or impaired glucose control, which are risk factors for delayed wound healing.
- D: While uncontrolled pain can be a concern for patient comfort and may indirectly affect wound healing by reducing mobility, it is not a direct risk factor for delayed wound healing like hyperemesis is.
Correct Answer is D
Explanation
A. Insisting on direct eye contact may be uncomfortable or distressing for some clients, particularly those with certain mental health conditions or cultural backgrounds. It's important to respect the client's comfort level.
B. Seating the client too far away can create a sense of distance and may hinder effective communication. A closer seating arrangement facilitates rapport and engagement.
C. Positioning the client's chair between the nurse's chair and the door may make the client feel trapped or uncomfortable, especially if they have concerns about their safety or autonomy.
D. Leaning in slightly when speaking to the client demonstrates attentiveness and engagement. It can also convey a sense of confidentiality and respect for the client's space.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.