Nokea
The client on spironolactone should avoid which of the following?
- A. Foods high in potassium
- B. Foods high in sodium
- C. Foods high in calcium
- D. Foods high in chloride
Correct Answer: A
Rationale: The correct answer is A: Foods high in potassium. Spironolactone is a potassium-sparing diuretic that can increase potassium levels in the body. Consuming foods high in potassium while taking spironolactone can lead to hyperkalemia, a serious condition characterized by high levels of potassium in the blood. The other choices (B: Foods high in sodium, C: Foods high in calcium, D: Foods high in chloride) are not directly contraindicated with spironolactone use. Sodium intake is typically restricted in patients taking diuretics, but it is not specifically related to spironolactone. Calcium and chloride levels are not significantly affected by spironolactone, so foods high in these minerals do not need to be avoided.
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What is the condition where the heart's mitral valve does not close properly, allowing blood to leak backward into the left atrium?
- A. Mitral regurgitation
- B. Aortic stenosis
- C. Tricuspid regurgitation
- D. Pulmonary hypertension
Correct Answer: A
Rationale: The correct answer is A: Mitral regurgitation. In this condition, the mitral valve fails to close properly, causing blood to flow back into the left atrium during ventricular contraction. This results in decreased forward blood flow and increased volume in the left atrium and ventricle. Mitral regurgitation can lead to symptoms like fatigue, shortness of breath, and heart murmur upon auscultation.
Now, let's analyze the other choices:
B: Aortic stenosis - This involves narrowing of the aortic valve, obstructing blood flow from the left ventricle to the aorta.
C: Tricuspid regurgitation - Involves backward flow of blood from the right ventricle to the right atrium due to a faulty tricuspid valve.
D: Pulmonary hypertension - Elevated blood pressure in the pulmonary arteries, usually caused by underlying conditions affecting the lungs or heart.
Therefore, the correct answer is A because it specifically describes
The client is receiving digoxin and has a potassium level of 2.8 mEq/L. What is the nurse's priority action?
- A. Hold the digoxin and notify the healthcare provider.
- B. Increase the dose of digoxin.
- C. Continue the current dose of digoxin.
- D. Administer potassium supplements.
Correct Answer: A
Rationale: The correct answer is A: Hold the digoxin and notify the healthcare provider. Digoxin toxicity is more likely to occur in patients with low potassium levels. With a potassium level of 2.8 mEq/L, the client is at risk for digoxin toxicity. Holding the digoxin and notifying the healthcare provider is the priority action to prevent potential harm to the client.
B: Increasing the dose of digoxin would exacerbate the risk of digoxin toxicity in a client with low potassium levels.
C: Continuing the current dose of digoxin without addressing the low potassium level could lead to digoxin toxicity.
D: Administering potassium supplements alone may not be sufficient to address the potential digoxin toxicity. Holding the digoxin is the priority action.
What procedure is used to remove fluid from the pleural space to help a patient breathe more easily?
- A. Thoracentesis
- B. Bronchoscopy
- C. Echocardiogram
- D. CT scan
Correct Answer: A
Rationale: The correct answer is A: Thoracentesis. This procedure involves inserting a needle or catheter into the pleural space to drain excess fluid, relieving pressure and allowing the patient to breathe more easily. Bronchoscopy (B) is used to visualize the airways, not remove fluid. Echocardiogram (C) is an ultrasound of the heart, not used for pleural fluid drainage. CT scan (D) is an imaging test, not a procedure for fluid removal. Thoracentesis is the appropriate choice for this scenario.
A patient with heart failure has tachypnea, severe dyspnea, and a SpO2 of 84%. The nurse identifies a nursing diagnosis of impaired gas exchange related to increased preload and mechanical failure. An appropriate nursing intervention for this diagnosis is
- A. Assist the patient to cough and deep breath every 2 hours
- B. Assess intake and output every 8 hours and weigh daily
- C. Encourage to alternate rest and activity to reduce cardiac workload
- D. Place the patient in a high Fowler's position with the legs horizontal
Correct Answer: D
Rationale: A high fowler's position increases the thoracic capacity, improving ventilation, and sitting with the legs horizontal will decrease venous return.
Nurse's role in hemodynamic monitoring.
- A. Data collection
- B. Interpretation
- C. Both A and B
- D. None of the above
Correct Answer: C
Rationale: Nurses collect data and interpret findings to guide interventions.