br>History and Physical

BP 100/60 mm Hg Pulse 52/min
Respiratory rate 20/min

Temperature 37.2" C (99.0° F)

A nurse is caring for an adolescent who is receiving treatment for heart failure. Based on the

client's chart findings, which of the following actions should the nurse plan to take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Administer furosemide.

Withhold digoxin.

Withhold spironolactone.

Administer ferrous sulfate.

Answer and Explanation

The Correct Answer is B

A. Administering furosemide may also be appropriate for managing heart failure symptoms, but the priority action based on the client's condition is to withhold digoxin.

B. The client's vital signs indicate bradycardia (pulse 52/min), which is a common adverse effect of digoxin, especially in the setting of heart failure. Withholding digoxin is necessary to prevent further exacerbation of bradycardia and potential toxicity.

C. Withholding spironolactone may be considered if there are concerns about electrolyte imbalances, but it is not the priority action in this scenario.

D. Administering ferrous sulfate is not indicated based on the client's chart findings; there is no indication of anemia or iron deficiency.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Beef liver - Beef liver is high in cholesterol and should be limited in the diet of someone with increased cholesterol levels.

B. Egg whites - Egg whites are low in cholesterol and can be a good source of protein for someone with increased cholesterol levels. It's the yolk of the egg that contains most of the cholesterol, so recommending egg whites is a good choice.

C. Steamed clams - Clams are low in cholesterol, but they are high in sodium, which may not be recommended for someone with increased cholesterol levels, depending on their overall dietary needs.

D. Broiled lobster - Lobster is high in cholesterol and should be limited in the diet of someone with increased cholesterol levels.

A. Hypotension B. Tachycardia C. Muscle cramps D. Hyperreflexia E. None F. None

Correct Answer is A

Explanation

A. Hypotension occurs because hypermagnesemia causes vasodilation, which lowers blood pressure. Magnesium acts as a smooth muscle relaxant, decreasing vascular resistance and contributing to hypotension. This is a common clinical finding when magnesium levels exceed the normal range.

B. Tachycardia is not expected with hypermagnesemia. Elevated magnesium levels depress the heart's electrical activity, leading to bradycardia (slow heart rate) instead of tachycardia.

C. Muscle cramps are typically associated with hypomagnesemia, which increases neuromuscular excitability. In hypermagnesemia, neuromuscular function is suppressed, leading to muscle weakness rather than cramps.

D. Hyperreflexia is a symptom of hypomagnesemia, not hypermagnesemia. In hypermagnesemia, neuromuscular activity is depressed, resulting in diminished or absent deep tendon reflexes

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing dietary teaching to a client who has an increased cholesterol level.Which of the following foods should the nurse recommend?

Correct Answer is B

Explanation

A nurse is assessing a client who has a magnesium level of 4.4 mEq/L. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is performing an admission assessment for a client who is to undergo a colonoscopy. The client informs the nurse that he took his prescribed medications before coming to the clinic. Which of the following medications is the priority to report to the provider?

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A nurse is caring for a client who is receiving continuous enteral feedings and reports diarrhea. Which of the following actions should the nurse take?

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