Nokea
The nurse is giving a client an IV bolus of heparin. What is the most important nursing action?
- A. Monitor the client's heart rate.
- B. Check the client's blood pressure.
- C. Check for signs of bleeding.
- D. Monitor the client's respiratory rate.
Correct Answer: A
Rationale: The correct answer is A: Monitor the client's heart rate. When administering an IV bolus of heparin, it is crucial to monitor the client's heart rate because heparin can cause serious side effects such as bleeding and heparin-induced thrombocytopenia, which can lead to changes in heart rate. Checking blood pressure (B) is also important but not as critical as monitoring heart rate. Checking for signs of bleeding (C) is necessary but should be done after monitoring the heart rate. Monitoring the client's respiratory rate (D) is not directly related to heparin administration.
You may also like to solve these questions
What is a condition where the airways become inflamed and narrow, making breathing difficult?
- A. Asthma
- B. Bronchitis
- C. Pleurisy
- D. Tuberculosis
Correct Answer: A
Rationale: Asthma is the correct answer because it is a condition characterized by inflammation and narrowing of the airways, leading to difficulty in breathing. This is due to various triggers causing the airways to become inflamed, swollen, and produce excess mucus, resulting in constriction and breathing difficulties. Bronchitis, Pleurisy, and Tuberculosis do not directly involve narrowing of the airways as their primary mechanism, making them incorrect choices. Bronchitis is inflammation of the bronchial tubes, Pleurisy is inflammation of the lining around the lungs, and Tuberculosis is a bacterial infection primarily affecting the lungs.
What is the condition where the body's immune system attacks its tissues, causing inflammation and damage?
- A. Autoimmune disease
- B. Infectious disease
- C. Allergic reaction
- D. Degenerative disease
Correct Answer: A
Rationale: The correct answer is A: Autoimmune disease. In autoimmune diseases, the immune system mistakenly attacks the body's tissues, leading to inflammation and damage. This occurs due to a breakdown in immune tolerance, resulting in the immune system targeting self-antigens. This leads to chronic inflammation and tissue damage. In contrast, infectious diseases are caused by pathogens, allergic reactions are responses to harmless substances, and degenerative diseases involve the gradual deterioration of tissues over time. Therefore, autoimmune disease best fits the description provided in the question.
Which condition involves the enlargement and weakening of the left ventricle of the heart, leading to reduced pumping ability?
- A. Dilated cardiomyopathy
- B. Hypertrophic cardiomyopathy
- C. Restrictive cardiomyopathy
- D. Pericarditis
Correct Answer: A
Rationale: The correct answer is A: Dilated cardiomyopathy. This condition involves the enlargement and weakening of the left ventricle, leading to reduced pumping ability. This results in the heart being unable to pump blood efficiently, causing symptoms like fatigue and shortness of breath. Hypertrophic cardiomyopathy (B) is the thickening of the heart muscle, not enlargement. Restrictive cardiomyopathy (C) involves stiffening of the heart muscle, not weakening. Pericarditis (D) is inflammation of the pericardium, not the heart muscle itself.
What is the primary BP effect of β-adrenergic blockers such as atenolol (Tenormin)?
- A. Vasodilation of arterioles by blocking movement of calcium into cells
- B. Decrease Na+ and water reabsorption by blocking the effect of aldosterone
- C. Decrease CO by decreasing rate and strength of the heart and renin secretion by the kidneys
- D. Vasodilation caused by inhibiting sympathetic outflow from the central nervous system (CNS)
Correct Answer: C
Rationale: β-blockers reduce cardiac workload and renin release.
Pneumothorax symptoms.
- A. Chest pain
- B. Shortness of breath
- C. Both A and B
- D. None of the above
Correct Answer: C
Rationale: Symptoms include sharp chest pain and difficulty breathing.