a client with a diagnosis of chronic heart failure is receiving digoxin what is the most important instruction the nurse should provide
Logo

Nursing Elites

HESI LPN

Adult Health Exam 1 Chamberlain

1. A client with a diagnosis of chronic heart failure is receiving digoxin. What is the most important instruction the nurse should provide?

Correct answer: B

Rationale: The most important instruction the nurse should provide is to monitor pulse rate daily before taking the medication. Digoxin can lead to bradycardia, so it is crucial to assess the pulse rate before administering the medication. This practice helps ensure that the heart rate is not too low for the safe use of digoxin. Choice A is incorrect as there is no specific requirement to take digoxin with a high-fiber meal. Choice C is also incorrect because there is no need to avoid dairy products while on digoxin. Choice D is incorrect since blurred vision is not a common side effect of digoxin; hence, it is not the most critical instruction to provide.

2. 4 hours after administration of 20U of regular insulin, the client becomes shaky and diaphoretic. What action should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take when a client becomes shaky and diaphoretic after insulin administration, indicating hypoglycemia, is to provide the client with carbohydrates like crackers and milk. Carbohydrates help raise blood glucose levels quickly. Encouraging the client to eat crackers and milk (Choice A) is the appropriate immediate action to address the hypoglycemia. Administering more insulin (Choice B) would worsen hypoglycemia, and recording the reaction (Choice D) is important but not the immediate action needed to treat the hypoglycemia.

3. A client with a diagnosis of bipolar disorder is taking lithium. What is the most important information the nurse should provide?

Correct answer: B

Rationale: The correct answer is B. Sodium levels can affect lithium levels in the body, so it is crucial to monitor sodium intake to prevent toxicity or subtherapeutic levels. Lithium is typically taken on an empty stomach to enhance absorption, making choice A more accurate than the original 'Take the medication with food.' Reporting weight gain, as mentioned in choice C, is important for monitoring side effects but is not as critical as ensuring proper lithium levels through sodium intake monitoring. Choice D, avoiding excessive caffeine intake, is not a priority concern directly related to lithium therapy.

4. A client with a leg fracture reports increased pain and swelling. What should the nurse suspect?

Correct answer: A

Rationale: Increased pain and swelling in a fracture could indicate compartment syndrome, a serious condition requiring urgent care. Compartment syndrome is characterized by increased pressure within a muscle compartment, leading to compromised blood flow and potential tissue damage. Deep vein thrombosis is less likely in this scenario as the symptoms are more indicative of compartment syndrome. Wound infection would typically present with localized signs of infection at the wound site, such as redness, warmth, and purulent drainage, rather than diffuse pain and swelling.

5. The nurse is caring for a client with a tracheostomy who is on mechanical ventilation. What is the priority nursing intervention?

Correct answer: A

Rationale: The priority nursing intervention for a client with a tracheostomy on mechanical ventilation is to suction the tracheostomy as needed. Suctioning is essential to maintain a clear airway and prevent respiratory distress. While ensuring tracheostomy ties are secure (choice B) is important, it is not as urgent as airway maintenance. Providing humidified oxygen (choice C) is beneficial but does not address the immediate need for airway clearance. Cleaning exudate around the tracheostomy site (choice D) is important for hygiene but takes precedence over ensuring airway patency through suctioning.

Similar Questions

A client is diagnosed with type 1 diabetes mellitus. Which instruction about insulin administration should the nurse emphasize?
A client with a diagnosis of diabetes mellitus is experiencing symptoms of hypoglycemia. What is the nurse's priority intervention?
The nurse is assessing a newborn and notes that the infant has a yellowish tint to the skin. What should the nurse do next?
A client with a diagnosis of osteoporosis is prescribed alendronate (Fosamax). What is the most important instruction the nurse should provide?
A client with asthma is prescribed a corticosteroid inhaler. What instruction should the nurse give about the inhaler?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses