a client with a history of congestive heart failure is prescribed digoxin lanoxin which assessment is most important for the nurse to obtain before ad
Logo

Nursing Elites

HESI LPN

Adult Health 2 Final Exam

1. A client with a history of congestive heart failure is prescribed digoxin (Lanoxin). Which assessment is most important for the nurse to obtain before administering this medication?

Correct answer: B

Rationale: The correct answer is B: Heart rate. Before administering digoxin to a client with a history of congestive heart failure, the nurse must assess the client's heart rate. Digoxin can cause bradycardia, so monitoring the heart rate is crucial to prevent potential complications. Assessing blood pressure, respiratory rate, and oxygen saturation are important assessments but are not as directly influenced by digoxin as heart rate is in this scenario. Blood pressure can be affected by various factors, including dehydration or other medications. Respiratory rate and oxygen saturation are more related to respiratory function and gas exchange, which are not the primary concerns when administering digoxin to a client with heart failure.

2. A client with diabetes exhibits a blood sugar of 350 mg/dL. What is the nurse's best action?

Correct answer: A

Rationale: In a client with diabetes presenting with a blood sugar level of 350 mg/dL, the best action for the nurse is to administer insulin as prescribed. High blood sugar levels can lead to complications like diabetic ketoacidosis, making prompt insulin administration crucial to lower the blood glucose level. Providing a carbohydrate-controlled snack would be inappropriate as it may further elevate blood sugar levels. Encouraging physical activity is not advisable when the blood sugar is significantly high, as exercise can raise blood sugar levels. Rechecking the blood sugar is necessary after administering insulin to monitor the response to treatment.

3. The client with a diagnosis of hypertension is being taught about lifestyle changes. Which recommendation is most important to include?

Correct answer: B

Rationale: Engaging in regular physical activity is crucial for individuals with hypertension as it helps lower blood pressure and improve cardiovascular health. Physical activity is known to have a significant impact on reducing hypertension and overall cardiovascular risk. Choice A, increasing sodium intake, is incorrect as reducing sodium is typically recommended for hypertension to help lower blood pressure. Choice C, avoiding foods high in fat, is beneficial for overall health but not the most crucial recommendation for hypertension management. Choice D, limiting fluid intake to 1 liter per day, is not a standard recommendation for hypertension unless advised by a healthcare provider for specific cases. Therefore, the most important recommendation for the client with hypertension is to engage in regular physical activity.

4. A client with a history of seizures is being discharged home. Which instruction is most important for the nurse to provide?

Correct answer: A

Rationale: The most important instruction for a client with a history of seizures being discharged home is to take their medication as prescribed. Consistent and timely intake of anti-seizure medication is vital in managing seizures and preventing episodes. While instructions like avoiding driving until the condition is stable, keeping a seizure diary, and avoiding alcohol consumption are important, none are as critical as ensuring proper medication adherence to control seizures effectively. Failure to take prescribed medications can lead to breakthrough seizures, compromising the patient's safety and seizure control.

5. A client requires application of an eye shield to the right eye. What should the nurse do in order to apply tape to anchor the shield most effectively?

Correct answer: C

Rationale: The correct way to apply tape to anchor an eye shield effectively is to attach the tape from the lower eyelid to the upper forehead. This method provides stability for the shield without putting pressure on the eye itself, thus helping to protect the eye. Choices A, B, and D are incorrect because taping from the cheek to the forehead, securing tape from the nose to the ear, or using circular bandaging around the head may not provide the necessary stability and protection required for the eye shield.

Similar Questions

Prior to administering morphine sulfate (Morphine), the nurse takes the client's vital signs. Based on which finding should the nurse withhold administration of the medication until the charge nurse is notified?
A client with chronic obstructive pulmonary disease (COPD) is using a metered-dose inhaler (MDI). What technique should the nurse emphasize?
A client is scheduled for a sigmoidoscopy and expresses anxiety about the procedure. What should the nurse do first?
What is the most important action to prevent catheter-associated urinary tract infections (CAUTIs) in a client with an indwelling urinary catheter?
Which client is at the highest risk for developing pressure ulcers?

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