Practice Exam Flashcards

The nurse is to administer digoxin elixir to a 6-month-old with a congenital heart defect. The nurse auscultates an apical pulse rate of 100. The nurse should:

Answer: Record the heart rate and administer the medication

Digoxin is a cardiac medication that slows the heart rate. For infants, the apical pulse should generally be above 90-110 beats per minute before administering digoxin to ensure it doesn't dangerously lower the heart rate. An apical pulse of 100 bpm is within the acceptable range for a 6-month-old, so the nurse should proceed with administering the medication and document the finding.

A mother of a 3-year-old hospitalized with lead poisoning asks the nurse to explain the treatment for her daughter. The nurse’s explanation is based on the knowledge that lead poisoning is treated with:

Answer: Chelating agents

Lead poisoning is primarily treated with chelating agents. These medications bind to lead in the body, forming a stable complex that can then be safely excreted through the urine. This process, known as chelation therapy, helps to remove the toxic lead from the body and reduce its harmful effects on various organ systems.

An 18-month-old is scheduled for a cleft palate repair. The usual type of restraints for the child with a cleft palate repair are:

Answer: Elbow restraints

After a cleft palate repair, it is crucial to prevent the child from touching or putting objects into their mouth to protect the delicate surgical site and promote healing. Elbow restraints are commonly used for this purpose as they prevent the child from bending their elbows, thereby keeping their hands away from their face while still allowing some arm movement.

A client with glaucoma has been prescribed Timoptic (timolol) eyedrops. Timoptic should be used with caution in the client with a history of:

Answer: Emphysema

Timolol (Timoptic) is a beta-blocker, and this class of medications can cause bronchoconstriction. In clients with respiratory conditions like emphysema, asthma, or COPD, beta-blockers can exacerbate breathing difficulties and lead to respiratory distress. Therefore, Timoptic should be used with extreme caution or is often contraindicated in individuals with a history of emphysema.

An elderly client who experiences nighttime confusion wanders from his room into the room of another client. The nurse can best help decrease the client’s confusion by:

Answer: Leaving a nightlight on during the evening and night shifts

Nighttime confusion, often referred to as 'sundowning,' in elderly clients can be worsened by disorientation in unfamiliar or dimly lit environments. Leaving a nightlight on provides visual cues, helps the client orient themselves to their surroundings, and reduces anxiety and confusion by making the environment less threatening and more recognizable during the night.

Which of the following is a common complaint of the client with end-stage renal failure?

Answer: Itching

Itching, or pruritus, is a very common and often distressing symptom experienced by clients with end-stage renal failure. This is primarily due to the accumulation of uremic toxins in the blood, as the kidneys are no longer able to effectively filter waste products. Other contributing factors can include dry skin and calcium-phosphate deposits.

Which of the following medication orders needs further clarification?

Answer: Coumadin 10mg PO

A complete medication order must specify the drug name, dose, route, and frequency of administration. The order 'Coumadin 10mg PO' is missing the frequency (e.g., daily, twice a day), which is essential information for safe and effective medication administration. Therefore, the nurse needs to seek clarification from the prescriber before administering this medication.

The best diet for the client with Meniere’s syndrome is one that is:

Answer: Low in sodium

Meniere's syndrome is characterized by an excess of fluid (endolymph) in the inner ear, leading to symptoms like vertigo, tinnitus, and hearing loss. A low-sodium diet is recommended because sodium can contribute to fluid retention in the body, including the inner ear, which can exacerbate the symptoms of Meniere's syndrome.

Which of the following findings is associated with right-sided heart failure?

Answer: Nocturnal polyuria

Right-sided heart failure leads to systemic venous congestion, causing fluid to accumulate in peripheral tissues, especially in the lower extremities during the day. When the client lies down at night, this accumulated fluid is reabsorbed into the circulation, increasing venous return to the heart and subsequently increasing renal blood flow, leading to increased urine production (nocturnal polyuria).