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1. A healthcare provider is reviewing the medical record of a client who is scheduled for an abdominal paracentesis. Which of the following actions should the healthcare provider take to prepare the client for this procedure?
- A. Assist the client to void
- B. Instruct the client to hold their breath
- C. Place the client in a lateral recumbent position
- D. Prepare to administer a sedative
Correct answer: A
Rationale: Assisting the client to void before a paracentesis is essential to reduce the risk of bladder injury during the procedure. Voiding helps empty the bladder, preventing accidental puncture during the insertion of the needle. Instructing the client to hold their breath is incorrect and can increase the risk of complications. Placing the client in a lateral recumbent position is not directly related to bladder safety during a paracentesis. Preparing to administer a sedative is not a standard preparation for this procedure and is not aimed at preventing bladder injury.
2. A nurse in a provider's office is collecting data from a preschooler. Which of the following findings should the nurse report to the provider?
- A. Heart rate 80/min
- B. Heart rate 90/min
- C. Respiratory rate 28/min
- D. Heart rate 146/min
Correct answer: D
Rationale: A heart rate of 146/min is abnormal for a preschooler and indicates tachycardia, which should be reported to the provider. Choices A, B, and C fall within normal ranges for a preschooler's heart rate (80-120/min) and respiratory rate (22-34/min), so they do not require immediate reporting. Option D is the correct answer as it deviates significantly from the normal range and may indicate an underlying health issue that needs attention.
3. A nurse is reviewing the plan of care for a client who is taking digoxin. Which of the following findings should the nurse monitor as an adverse effect of this medication?
- A. Hypokalemia
- B. Hypernatremia
- C. Hypertension
- D. Tachycardia
Correct answer: A
Rationale: The correct answer is A: Hypokalemia. Hypokalemia is an adverse effect of digoxin. Digoxin can cause hypokalemia, which increases the risk of toxicity. Monitoring potassium levels is crucial when a client is taking digoxin. Choices B, C, and D are incorrect as hypernatremia, hypertension, and tachycardia are not directly associated with digoxin use.
4. What is the healthcare provider's role in providing patient education about hypertension management?
- A. Encourage lifestyle modifications and medication adherence
- B. Advise patients to avoid physical activity
- C. Recommend a low-sodium diet
- D. Increase potassium in the diet
Correct answer: A
Rationale: The correct answer is A: Encourage lifestyle modifications and medication adherence. Patient education in hypertension management should focus on encouraging lifestyle changes like a healthy diet, exercise, stress management, and adherence to prescribed medications. Choices B, C, and D are incorrect because advising patients to avoid physical activity, recommending a low-sodium diet, and increasing potassium intake, although related to hypertension management, do not encompass the comprehensive approach needed for effective patient education on this topic.
5. The physician orders risperidone (Risperdal) for a client with Alzheimer's disease. The nurse anticipates administering this medication to help decrease which of the following behaviors?
- A. Sleep disturbances
- B. Concomitant depression
- C. Agitation and assaultiveness
- D. Confusion and withdrawal
Correct answer: C
Rationale: The correct answer is C: Agitation and assaultiveness. Risperidone is commonly prescribed for clients with Alzheimer's disease to reduce symptoms of agitation and aggressive behavior. This medication helps in managing challenging behaviors often seen in individuals with Alzheimer's. Choice A, sleep disturbances, is incorrect as risperidone is not primarily indicated for treating sleep issues in Alzheimer's patients. Choice B, concomitant depression, is also incorrect as risperidone is not the first-line treatment for depression in Alzheimer's disease. Choice D, confusion and withdrawal, is incorrect as risperidone does not directly target these symptoms in Alzheimer's patients.
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