The nurse is caring for a child with congestive heart failure (CHF). The nurse provides instructions to the mother regarding the procedure for administration of the prescribed digoxin (Lanoxin)
Which of the following statements, if made by the mother, indicates a need for further education? 1. "I can mix the medication with food."
2. "If more than one dose is missed, I need to call the physician."
3. "I need to take the child's pulse before administering the medication."
4. "If the child vomits after being given the medication, I should not repeat the dose."
1
Rationale: Medication should not be mixed with food, because this method of administration would not ensure that the child received the prescribed dose. The parents need to be instructed that if the child vomits after the digoxin is administered, they are not to repeat the dose. Addi-tionally, the parents should be instructed that if a dose is missed and is not identified until 4 or more hours later, the dose should not be administered. If more than one dose is missed, the phy-sician needs to be notified.
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When writing an actual nursing diagnosis, the "related to" part links the first two parts of the diagnosis. Complete the following nursing diagnosis appropriately. Dehydration related to:
a. lack of fluid intake. b. excessive food intake. c. lack of exercise. d. bed rest.
A client who is 5 feet 7 inches tall and weighs 160 pounds believes that her size-9 feet are enormous
compared with the rest of her body. She has visited orthopedic surgeons to see if surgery to reduce the length of her feet is possible. She spends hours trying to buy shoes that make her feet look smaller, and she prefers social interactions where she can sit with her feet concealed under a table. The nurse can assess that the client's symptoms are consistent with a. hypochondriasis. b. somatoform pain disorder. c. body dysmorphic disorder. d. depersonalization disorder.
A patient with a 60% burn in the acute phase of treatment develops a tense abdomen, decreasing urine output, hypercapnia, and hypoxemia. Based on this assessment, the nurse anticipates interventions to evaluate and treat the patient for:
a. acute kidney injury. b. acute respiratory distress syndrome. c. intraabdominal hypertension. d. disseminated intravascular coagulation disorder.
The client is being treated with heparin and also with nitroglycerin. The nurse anticipates that the interaction of the two drugs will produce which effect?
a. Inadequate effect from the nitroglycerin b. Decreased effect from the heparin c. Toxic dose of the nitroglycerin d. Increased effect from the heparin