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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Alendronate should be taken on an empty stomach, preferably in the morning, and the client should wait at least 30 minutes before eating or drinking anything other than water.
B. Alendronate should be taken in the morning, not at bedtime, to reduce the risk of esophageal irritation and ensure proper absorption.
C. Taking alendronate with 8 ounces of water helps facilitate proper absorption and reduces the risk of esophageal irritation.
D. Increasing caffeine intake while taking alendronate is not recommended, as caffeine can interfere with calcium absorption and potentially worsen osteoporosis.
Correct Answer is A
Explanation
A. A flat anterior fontanel can indicate dehydration in infants, so this finding does not indicate effective treatment.
B. Oliguria, or decreased urine output, is a sign of dehydration and would not indicate effective treatment.
C. Oral intake of 4 oz every 3 hours indicates that the infant is able to drink fluids and is likely rehydrated, indicating effective treatment.
D. A capillary refill of 4 seconds is prolonged and can indicate poor perfusion, which is not indicative of effective treatment for dehydration.
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