the client is receiving digoxin and complains of nausea what is the nurses priority action the client is receiving digoxin and complains of nausea what is the nurses priority action
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Nursing Elites

ATI RN

Cardiovascular System Practice Exam

1. The client is receiving digoxin and complains of nausea. What is the nurse’s priority action?

Correct answer: A

Rationale: The correct answer is to check the client’s digoxin level (Choice A). Nausea can be a sign of digoxin toxicity, so assessing the digoxin level is crucial to determine if the medication dosage needs adjustment. Continuing the current dose of digoxin (Choice B) may worsen the symptoms if toxicity is present. Administering an antiemetic (Choice C) may provide temporary relief but does not address the underlying issue of digoxin toxicity. Discontinuing digoxin immediately (Choice D) without assessing the digoxin level can be harmful if the medication is within the therapeutic range.

2. A female patient is taking combined hormonal contraceptives to prevent pregnancy. She visits the gynecology clinic and is noted to have a blood pressure of 176/102 mm Hg. The patient is started on enalapril mesylate 10 mg. In collaboration with the primary care provider, what other patient teaching should be provided based on her current medication regimen?

Correct answer: A

Rationale: Women on hormonal contraceptives and antihypertensives like enalapril should be counseled to adopt a low-salt diet if severe hypertension occurs. This dietary modification can help in managing blood pressure levels. Instructing to discontinue the contraceptives is crucial in cases of severe hypertension as it poses an increased risk of cardiovascular events. Instructing on relaxation techniques may have some benefits in reducing stress levels but addressing the root cause, such as discontinuing contraceptives in this scenario, is more critical. There is no rationale for increasing the contraceptive dose when hypertension is present; in fact, it should be stopped to prevent complications.

3. A patient with schizophrenia is prescribed risperidone. The nurse should monitor the patient for which common side effect of this medication?

Correct answer: B

Rationale: When a patient is prescribed risperidone, an atypical antipsychotic, the nurse should monitor for weight gain as it is a common side effect of this medication. Weight gain can occur due to metabolic changes and increased appetite associated with risperidone use. Agranulocytosis is a severe decrease in a type of white blood cells, and it is not a common side effect of risperidone. Hair loss and hyperthyroidism are also not typically associated with risperidone use.

4. How does abuse and maltreatment tend to affect a child's ability to relate to others?

Correct answer: B

Rationale: The correct answer is B. Abuse and maltreatment tend to result in difficulties in forming healthy relationships and may lead to a disorganized and disoriented attachment style. Choice A is incorrect because abuse and maltreatment usually hinder the development of strong and healthy relationships. Choice C is incorrect as abuse and maltreatment significantly impact a child's social development. Choice D is incorrect because abuse and maltreatment do not promote independence in forming new relationships but rather create barriers to forming healthy connections.

5. The nurse is caring for a child after a cleft palate repair who is on a clear liquid diet. Which feeding device should the nurse use to deliver the clear liquid diet?

Correct answer: D

Rationale: An open cup is recommended for feeding after cleft palate repair to prevent injury to the surgical site and avoid creating negative pressure, which could disrupt the repair.

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