Prescription for digoxin

🟨 Digoxin is a critical finding because furosemide can cause further potassium loss, and hypokalemia increases the risk of digoxin toxicity.

🟨 When potassium is low, digoxin binds more easily at its action sites, which can lead to dangerous cardiac effects.

🟨 This client already has a potassium level below normal, so adding furosemide could worsen the imbalance and increase harm.

🟨 The nurse should recognize that concurrent digoxin therapy makes the low-potassium situation especially concerning before giving the new diuretic.

🟨 Therefore, the prescription for digoxin is one of the findings that indicates a contraindication or major concern requiring follow-up.

Client verbal report

🟨 The client reports diarrhea, dry mouth, and unusual thirst for the past three days, which suggests possible fluid volume depletion.

🟨 Furosemide is a loop diuretic, so giving it to a client who may already be dehydrated can worsen fluid loss.

🟨 This can increase the risk of hypovolemia, dizziness, electrolyte imbalance, and renal compromise.

🟨 The nurse should identify these symptoms as important assessment findings that need further evaluation before administering the medication.

🟨 Therefore, the client verbal report is one of the findings that indicates a contraindication or significant concern.

Potassium level

🟨 The client’s potassium level is 3.2 mEq/L, which is below the expected range and indicates hypokalemia.

🟨 Furosemide can further lower potassium because it increases urinary excretion of electrolytes.

🟨 Worsening hypokalemia can lead to muscle weakness, dysrhythmias, and increased risk of digoxin toxicity.

🟨 Because the potassium is already low before the first dose, the nurse should recognize this as a serious reason to question the prescription.

🟨 Therefore, the potassium level is one of the findings that indicates a contraindication or major concern.

Blood pressure

🟨The blood pressure of 122/68 mm Hg is within an acceptable range and does not by itself indicate a contraindication to furosemide.

🟨Although furosemide can lower blood pressure, this current reading is not the most concerning finding here.

BUN

🟨The BUN of 19 mg/dL is within the expected reference range and does not independently suggest renal impairment severe enough to contraindicate furosemide.

🟨It is less concerning than the signs of dehydration and low potassium.

Prescription for diltiazem

🔷 Diltiazem is an important finding because it can increase simvastatin levels in the body by affecting the enzyme system that metabolizes the statin.

🔷 Higher simvastatin levels raise the risk of statin-associated muscle injury, including myopathy and rhabdomyolysis.

🔷 When simvastatin is prescribed with diltiazem, the nurse should recognize a significant drug interaction and verify that the statin is safe to administer.

🔷 This interaction becomes even more concerning when the client already has muscle symptoms and an elevated creatine kinase level.

🔷 Therefore, the prescription for diltiazem is a contraindication or serious concern before administering simvastatin.

Client report of muscle aches

🔷Muscle aches are a classic warning sign of statin-induced myopathy.

🔷Because simvastatin can worsen muscle injury, a client already reporting muscle pain should be assessed carefully before the medication is given.

🔷This symptom is especially concerning because it may indicate early muscle breakdown rather than a minor expected effect.

🔷The nurse should identify this report as a possible adverse reaction that requires follow-up with the provider.

🔷Therefore, the client report of muscle aches is a contraindication or major concern for simvastatin administration.

Creatine kinase

🔷The client’s creatine kinase is 200 units/L, which is above the expected range and suggests possible muscle injury.

🔷Elevated CK in a client who also reports muscle aches increases concern for statin-associated myopathy.

🔷Giving simvastatin in this situation could worsen muscle damage and increase the risk of serious complications such as rhabdomyolysis.

🔷A statin should be questioned when there are signs of active muscle toxicity.

🔷Therefore, the creatine kinase finding is a contraindication or significant concern before administration.

BUN

🔷The BUN of 15 mg/dL is within the expected range and does not independently indicate a contraindication to simvastatin.

🔷It does not suggest the immediate muscle-related risk that is present in this case.

Blood pressure

🔷The blood pressure of 140/90 mm Hg is elevated, but this is not a direct contraindication to simvastatin.

🔷The more urgent concerns are the signs of muscle toxicity and the drug interaction with diltiazem.

🔷 After a bone marrow aspiration, the nurse applies firm pressure to the site to help prevent bleeding and promote hemostasis.

🔷 The procedure commonly involves puncturing bone to obtain marrow, so postprocedure bleeding control is important.

🔷 Pressure is especially necessary because the aspiration site can ooze after the needle is removed.

🔷 This statement correctly describes an expected nursing action and appropriate client teaching.

🔷 Therefore, the statement the nurse should include is “I will hold pressure to the site after the procedure.”

“You will have the bone marrow taken from your femur.”

🔷Bone marrow aspiration is usually obtained from the iliac crest or sternum in adults, not commonly from the femur.

🔷This statement gives incorrect procedural teaching.

“You will need to fast for 2 hours before the procedure.”

🔷Fasting is not typically required for a routine bone marrow aspiration under local anesthesia.

🔷This instruction is not standard teaching for the procedure.

“You will not receive a local anesthetic agent for this procedure.”

🔷A local anesthetic is generally used to numb the skin and tissue before aspiration.

🔷The client may still feel pressure, but the area is usually anesthetized.

🟩 A client who is 2 days postoperative with hypoactive bowel sounds and cramping abdominal pain is likely experiencing decreased bowel motility, such as a postoperative ileus.

🟩 The first action is to promote return of peristalsis through early ambulation, which is one of the safest and most effective interventions.

🟩 Walking helps stimulate bowel function, reduce gas retention, and improve overall recovery after abdominal surgery.

🟩 This addresses the likely cause of the discomfort rather than simply masking symptoms.

🟩 Therefore, the nurse should first ambulate the client in the hallway.

Offer an analgesic medication.

🟩Pain medication may relieve discomfort, but it does not treat the underlying decreased bowel motility.

🟩Some analgesics, especially opioids, can worsen constipation or ileus.

Administer a glycerin suppository.

🟩A suppository is not the first action for postoperative hypoactive bowel sounds and cramping after abdominal surgery.

🟩The bowel should first be stimulated with less invasive measures such as ambulation.

Request the client to be NPO.

🟩The question asks for the first action, and hypoactive bowel sounds with mild cramping 2 days after surgery are commonly addressed first with ambulation.

🟩NPO status may be considered later if symptoms worsen or obstruction is suspected.

🟨 In a client with hemophilia, even a small laceration can lead to prolonged bleeding because of impaired clotting.

🟨 After applying a sterile dressing, the next priority is to maintain direct pressure to help control bleeding mechanically.

🟨 Direct pressure supports clot formation and is the immediate first-line intervention for external bleeding.

🟨 This is more urgent than checking pulses or waiting to see whether the bleeding stops on its own.

🟨 Therefore, the nurse should next maintain direct pressure over the site.

Whether the bleeding has stopped.

🟨Simply checking the site is not enough when the client has a known bleeding disorder.

🟨The priority is to actively control the bleeding with pressure.

Obtain a radial pulse.

🟨Checking circulation may be appropriate in other contexts, but it does not address the immediate bleeding problem.

🟨The nurse must first control hemorrhage.

Reinforce the dressing over the site.

🟨Adding more dressing without maintaining direct pressure is less effective in stopping active bleeding.

🟨Pressure is the key intervention.

🟥 Community-acquired pneumonia generally requires standard precautions and sometimes droplet precautions, depending on the organism, but it does not routinely require an N95 respirator.

🟥 An N95 mask is typically reserved for airborne precautions, such as tuberculosis, measles, or varicella.

🟥 During respiratory suctioning, the nurse should wear appropriate PPE such as gloves, gown, eye protection, and a surgical mask if splash or droplet exposure is possible.

🟥 Saying an N95 is required indicates misunderstanding of the level of isolation needed for routine community-acquired pneumonia.

🟥 Therefore, the statement indicating the need for further teaching is “I will need to wear an N95 respiratory mask while suctioning the client.”

“I should limit my conversation with the client while wearing my mask.”

🟥Limiting unnecessary talking while masked is reasonable because it helps maintain focus and reduce contamination risks during a procedure.

🟥This statement does not reflect incorrect PPE use.

“After completing the suctioning, I should remove my gloves.”

🟥Gloves should be removed after completing the procedure as part of proper PPE removal.

🟥This statement reflects correct infection-control practice.

“I will pull the glove cuff over the wrist of the gown.”

🟥Gloves are correctly worn over the gown cuffs to protect exposed skin and maintain a barrier.

🟥This demonstrates appropriate PPE technique.

🟪 A client with a tracheostomy who is restless and has crackles may have retained secretions obstructing the airway.

🟪 Restlessness can be an early sign of hypoxia, and crackles suggest fluid or secretions that the client may not be clearing effectively.

🟪 The priority is to maintain airway patency, so suctioning is the most immediate intervention.

🟪 Removing secretions can improve oxygenation, reduce respiratory distress, and prevent further airway compromise.

🟪 Therefore, the nurse should perform suctioning.

Instill saline into the tubing.

🟪Routine saline instillation before suctioning is not recommended because it can worsen hypoxia and does not reliably improve secretion removal.

🟪The client needs direct airway clearance.

Increase the humidification.

🟪Humidification may help prevent future thick secretions, but it will not immediately relieve current retained secretions causing distress.

🟪The priority is airway suctioning now.

Check the cuff pressure.

🟪Cuff pressure is important for tracheostomy management, but it does not address the immediate signs of secretion retention and possible hypoxia.

🟪Airway clearance takes priority.

🔷 Ferrous sulfate is absorbed better in the presence of vitamin C.

🔷 Raw oranges are rich in ascorbic acid, which helps convert iron into a form that is easier for the body to absorb.

🔷 This can improve the effectiveness of oral iron therapy in clients who have anemia.

🔷 Teaching the client to take iron with a vitamin C source can help increase absorption and support correction of iron deficiency.

🔷 Therefore, the nurse should recommend raw oranges.

Cheese

🔷Cheese is high in calcium, and calcium can decrease iron absorption.

🔷It is not the best food choice to take with ferrous sulfate.

Baked potatoes

🔷Potatoes may contain some nutrients, but they are not the best source of vitamin C compared with oranges for enhancing iron absorption.

🔷This option is less effective for the stated purpose.

Oatmeal

🔷Oatmeal contains substances such as phytates that can reduce iron absorption.

🔷It is not the ideal food to improve ferrous sulfate uptake.