Question

A nurse is reviewing the morning laboratory results of electrolytes for four clients who are receiving digoxin. Which of the following clients should the nurse identify as being at risk for developing digoxin toxicity?

Answer 1

Correct Answers:

A client taking furosemide for chronic hypertension

Rationale :

🟢 Furosemide, a loop diuretic, promotes the excretion of sodium, chloride, and potassium, leading to hypokalemia.

🟢 Low serum potassium levels enhance the binding of digoxin to cardiac muscle, significantly increasing the risk of digoxin toxicity.

🟢 Toxicity manifests as nausea, vomiting, visual disturbances (e.g., yellow halos), and cardiac arrhythmias due to increased myocardial irritability.

🟢 Nurses should closely monitor potassium levels and electrocardiogram (ECG) changes and may anticipate a potassium supplement or dose adjustment to prevent toxicity.

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Answer 2

Correct Answers

Blank 1 Correct Option: the allergy list
Blank 2 Correct Option: with the client
Blank 3 Correct Option: the medication is not contraindicated

Rationale :

💠 1. Reviewing the allergy list

💠 The nurse must carefully review the client’s documented allergy list before administering any medication.

💠 This step ensures awareness of all known drug allergies or hypersensitivity reactions that could endanger the client.

💠 Reviewing this list helps prevent the administration of drugs that might cause anaphylaxis, rash, or respiratory distress.

💠 It also maintains continuity and accuracy of care by keeping all healthcare team members informed about potential medication risks.

💠 2. Confirming with the client

💠 The nurse should always verify allergies directly with the client to confirm the accuracy of medical records.

💠 This step allows the nurse to obtain details such as the type, severity, and timing of allergic reactions.

💠 Confirmation ensures that any new allergies or outdated entries are updated promptly in the client’s chart.

💠 It reinforces effective communication and patient safety, helping to prevent unnecessary exposure to harmful medications.

💠 3. Ensuring the medication is not contraindicated

💠 Before administration, the nurse must confirm that the prescribed drug is not related to any known allergens on the list.

💠 Certain medications share cross-reactive properties (e.g., penicillin and cephalosporins), increasing the risk of allergic reactions.

💠 This action helps prevent recurrent hypersensitivity or anaphylaxis and ensures adherence to safe medication practices.

💠 It also upholds the five rights of medication administration, particularly the right drug and right patient.

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Answer 3

Correct Answers:

Check the client's vital signs.

Rationale :

🟢 The priority nursing action after a medication error is to assess the client’s current condition, starting with obtaining vital signs. This step determines if the client is experiencing any adverse effects or physiological changes resulting from the incorrect administration.

🟢 Nifedipine, a calcium channel blocker, can cause hypotension, bradycardia, dizziness, or syncope; therefore, prompt assessment helps identify complications early.

🟢 Immediate evaluation provides crucial data to guide subsequent interventions, such as notifying the provider or initiating emergency support if the client’s condition is unstable.

🟢 Once the client’s status is stabilized and assessed, the nurse should proceed with other responsibilities like notifying the charge nurse, documenting the event, and completing an occurrence report as per institutional policy.

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Answer 4

Correct Answers

Blank 1 Correct Option: urinary stasis
Blank 2 Correct Option: urinary incontinence

Rationale :

💠 1. Urinary stasis

💠 Urinary stasis occurs when urine remains in the bladder for extended periods due to impaired mobility, decreased sensation, or incomplete bladder emptying. This condition provides an ideal environment for bacterial growth, significantly increasing the risk of urinary tract infection (UTI).

💠 Clients with limited mobility following surgery, such as a hip arthroplasty, are unable to ambulate to the bathroom regularly, which reduces bladder emptying efficiency.

💠 Additionally, incontinence episodes can mask incomplete voiding, allowing residual urine to remain in the bladder. Continuous assessment, timely toileting, and bladder training interventions help prevent stasis and infection.

💠 2. Urinary incontinence

💠 Urinary incontinence is the involuntary loss of urine, indicating that the bladder is not being emptied under voluntary control. In this client, incontinence is likely caused by immobility, decreased awareness, and potential postoperative confusion.

💠 When a client is incontinent, urine pooling in the bladder can lead to partial emptying or retention, predisposing them to stasis and bacterial colonization.

💠 The nurse should monitor urinary output patterns, assist with toileting schedules, and maintain skin integrity to prevent irritation or infection.

💠 Addressing incontinence is crucial not only for comfort and dignity but also for reducing the risk of UTI and renal complications associated with stagnant urine.

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Answer 5

Correct Answers:

A reddened area over the sacrum

Rationale :

🔵 A reddened area over the sacrum is an early indication of a pressure injury, a common and serious complication of prolonged immobility in older adults.

🔵 When a client remains in one position for an extended period, continuous pressure over bony prominences such as the sacrum impedes capillary blood flow, leading to tissue ischemia and cell death.

🔵 Older adults are particularly vulnerable due to reduced skin elasticity, decreased subcutaneous fat, and impaired circulation, which delay wound healing.

🔵 Regular repositioning every two hours, using pressure-relieving devices, and maintaining clean, dry skin are essential nursing interventions to prevent pressure injuries in immobile clients.

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Answer 6

Correct Answers:

Respiratory rate

Rationale :

🔴 Meperidine is an opioid analgesic that depresses the central nervous system, leading to a decreased respiratory rate and depth.

🔴 Monitoring the client’s respiratory rate is the priority assessment because opioid-induced respiratory depression is life-threatening and can occur rapidly after administration.

🔴 Early detection of a declining respiratory rate (below 12 breaths/min) allows the nurse to intervene promptly, such as stimulating the client, administering oxygen, or preparing for naloxone administration.

🔴 Continuous monitoring of respiratory function ensures safe pain management and prevents hypoxia or cardiac arrest.

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Answer 7

Correct Answers:

Isosorbide

Rationale :

🟣 Isosorbide is a nitrate medication used to treat angina by dilating blood vessels, thereby lowering blood pressure.

🟣 When combined with sildenafil (Viagra), a phosphodiesterase-5 inhibitor, the effects of vasodilation are dangerously intensified, leading to severe hypotension and possible cardiovascular collapse.

🟣 This drug interaction is absolutely contraindicated, and clients must be educated never to take nitrates and sildenafil within the same 24-hour period.

🟣 The nurse should notify the provider and educate the client about the potential for syncope, dizziness, and myocardial ischemia if these drugs are combined.

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Answer 8

Correct Answers:

Develop a comprehensive care plan with the client and family.

Rationale :

🟢 In hospice care, the focus is on comfort, dignity, and quality of life, respecting the client’s wishes and family involvement.

🟢 Developing a comprehensive care plan allows the nurse, client, and family to collaborate in addressing symptom management, emotional needs, and end-of-life goals.

🟢 This plan ensures that appropriate resources, equipment, and professional support are available at home to maintain comfort and safety.

🟢 Collaborative planning also helps family caregivers understand their roles and access ongoing support from the interdisciplinary hospice team.

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Answer 9

Correct Answers:

Prednisone

Rationale :

🟡 Prednisone, a glucocorticoid, raises blood glucose levels by stimulating gluconeogenesis and decreasing peripheral glucose utilization.

🟡 For a client taking metformin to manage type 2 diabetes, prednisone can counteract the drug’s hypoglycemic effect, leading to hyperglycemia and poor glycemic control.

🟡 Nurses should monitor blood glucose levels closely and notify the provider if corticosteroids are required, as dosage adjustments of antidiabetic medications may be needed.

🟡 Alternative anti-inflammatory medications may be considered to avoid complications related to steroid-induced hyperglycemia.

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Answer 10

Correct Answers:

Clean the least-soiled areas prior to cleaning the most-soiled areas

Rationale :

🔵 The principle of medical asepsis requires cleaning from cleanest to dirtiest areas to prevent the spread of microorganisms and reduce infection risk.

🔵 Washing the least-soiled areas first prevents contaminants from entering other parts of the body or clean washcloth areas.

🔵 This approach maintains skin integrity and hygiene, especially in vulnerable populations such as older adults or those with compromised immunity.

🔵 Using fresh water and washcloths as needed also minimizes cross-contamination and promotes patient comfort during hygiene care.

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ATI Medical surgical content assessment 1

No.

1 :
A nurse is reviewing the morning laboratory results of electrolytes for four clients who are receiving digoxin. Which of the following clients should the nurse identify as being at risk for developing digoxin toxicity?

2 :
A nurse is monitoring a client in the emergency department

Correct Answers

3 :
A nurse is administering morning medications and realizes that nifedipine was administered to the wrong client. Which of the following is the priority nursing action?

4 :
A nurse is assisting with the care of a client who has impaired mobility.

Correct Answers

5 :
An older adult client in a long-term care facility had a stroke 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility?

6 :
A nurse is administering meperidine 100 mg IM for a client who is admitted with a pelvic fracture. Following the injection, which of the following data is the priority for the nurse to check?

7 :
A nurse is collecting data from a client who takes several daily medications and states that he wants to ask the provider for a prescription for sildenafil. The nurse knows that sildenafil is contraindicated due to an interaction with which of the following client's medications?

8 :
A nurse is coordinating care for a client in hospice with metastatic breast cancer who has expressed a desire to remain at home. Which action should the nurse prioritize to support the client's wish?

9 :
A nurse is collecting data from a client who takes metformin for type 2 diabetes. Which of the following medications is contraindicated for this client due its effect on blood glucose levels?

10 :
A nurse is assisting a client with personal hygiene care. Which of the following actions should the nurse take to reduce the risk of infection?

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ATI Medical surgical content assessment 1

No.

1 : A nurse is reviewing the morning laboratory results of electrolytes for four clients who are receiving digoxin. Which of the following clients should the nurse identify as being at risk for developing digoxin toxicity?

2 : A nurse is monitoring a client in the emergency department

Correct Answers

3 : A nurse is administering morning medications and realizes that nifedipine was administered to the wrong client. Which of the following is the priority nursing action?

4 : A nurse is assisting with the care of a client who has impaired mobility.

Correct Answers

5 : An older adult client in a long-term care facility had a stroke 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility?

6 : A nurse is administering meperidine 100 mg IM for a client who is admitted with a pelvic fracture. Following the injection, which of the following data is the priority for the nurse to check?

7 : A nurse is collecting data from a client who takes several daily medications and states that he wants to ask the provider for a prescription for sildenafil. The nurse knows that sildenafil is contraindicated due to an interaction with which of the following client's medications?

8 : A nurse is coordinating care for a client in hospice with metastatic breast cancer who has expressed a desire to remain at home. Which action should the nurse prioritize to support the client's wish?

9 : A nurse is collecting data from a client who takes metformin for type 2 diabetes. Which of the following medications is contraindicated for this client due its effect on blood glucose levels?

10 : A nurse is assisting a client with personal hygiene care. Which of the following actions should the nurse take to reduce the risk of infection?

1 :
A nurse is reviewing the morning laboratory results of electrolytes for four clients who are receiving digoxin. Which of the following clients should the nurse identify as being at risk for developing digoxin toxicity?

2 :
A nurse is monitoring a client in the emergency department

3 :
A nurse is administering morning medications and realizes that nifedipine was administered to the wrong client. Which of the following is the priority nursing action?

4 :
A nurse is assisting with the care of a client who has impaired mobility.

5 :
An older adult client in a long-term care facility had a stroke 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility?

6 :
A nurse is administering meperidine 100 mg IM for a client who is admitted with a pelvic fracture. Following the injection, which of the following data is the priority for the nurse to check?

7 :
A nurse is collecting data from a client who takes several daily medications and states that he wants to ask the provider for a prescription for sildenafil. The nurse knows that sildenafil is contraindicated due to an interaction with which of the following client's medications?

8 :
A nurse is coordinating care for a client in hospice with metastatic breast cancer who has expressed a desire to remain at home. Which action should the nurse prioritize to support the client's wish?

9 :
A nurse is collecting data from a client who takes metformin for type 2 diabetes. Which of the following medications is contraindicated for this client due its effect on blood glucose levels?

10 :
A nurse is assisting a client with personal hygiene care. Which of the following actions should the nurse take to reduce the risk of infection?