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A client admitted due to emergent hypertension is about to be discharged. The nurse is giving instructions about dietary modifications. Which food choice by the client would indicate an accurate understanding of a low fat, low cholesterol diet?
- A. Macaroni and cheese
- B. Fish and chips
- C. Turkey breast salad
- D. Pepperoni pizza
Correct Answer: C
Rationale: Turkey breast salad is low in fat and cholesterol, suitable for a heart-healthy diet, unlike the other high-fat options.
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The nurse should be prepared to obtain which prescription from the primary healthcare provider for a client with an oral temperature of 101 ° F (38.3° C) and an ECG tracing? Select all that apply.
- A. 0.9% saline bolus
- B. Enalapril
- C. Levothyroxine
- D. Metoclopramide
- E. Acetaminophen
Correct Answer: E
Rationale: Saline bolus is not indicated for fever alone without dehydration. B: Incorrect - Enalapril is for hypertension or heart failure, not fever or ECG issues. C: Incorrect - Levothyroxine is for hypothyroidism, not relevant here. D: Incorrect - Metoclopramide is for nausea, not fever or cardiac issues. E: Correct - Acetaminophen is appropriate for fever reduction.
The nurse is watching the monitor of a client wearing a continuous cardiac monitor when it begins to alarm and fails to display any QRS complexes. Which nursing intervention should the nurse do first?
- A. Press record on the electrocardiogram
- B. Check the client's lead placement
- C. Call the code team
- D. Contact the health care provider
Correct Answer: B
Rationale: Absent QRS complexes may result from loose or disconnected leads, so checking lead placement is the first step.
The following scenario applies to the next 1 items
The nurse cares for a client following a cardiac arrest
Item 1 of 1
Admission Notes
2000 - 36-year-old was found unresponsive and with no pulse after collapsing at his job. Cardiopulmonary resuscitation (CPR) was started at the scene. The client was successfully resuscitated in the emergency department. The client was intubated, and central vascular access was established.
2130 - The client was transferred to the intensive care unit. Shortly after the transfer, the client converted to ventricular fibrillation. Code blue was called. CPR was delivered over 2 minutes, and a palpable carotid pulse was not assessed. The client's current cardiac monitor shows asystole.
The next essential intervention is the administration of…………… followed by ……………….. for a client in asystole post-cardiac arrest.
- A. Epinephrine
- B. Amiodarone
- C. Sodium bicarbonate
- D. Defibrillation
- E. Resuming CPR
- F. Cardioversion
Correct Answer: A,E
Rationale: Epinephrine is given in asystole to stimulate cardiac activity. E: Correct - CPR resumes immediately after medication to restore circulation. B, C, D, F: Incorrect - Amiodarone, sodium bicarbonate, defibrillation, and cardioversion are not indicated for asystole.
The nurse has instructed a client who is scheduled to have a transesophageal echocardiogram (TEE). Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I will need to take antibiotics for one week following this test.
- B. This test will determine if I have any blood clots in my heart.
- C. I will receive general anesthesia for this procedure.
- D. I may feel a flushing sensation when the contrast dye is given.
Correct Answer: B
Rationale: TEE is used to detect intracardiac thrombi, such as in atrial fibrillation, making this statement correct.
The nurse is caring for a client newly admitted with infective endocarditis (IE). The nurse should plan for which intervention in the client's care plan?
- A. initiating contact and droplet precautions
- B. obtain a prescription for intravenous antivirals
- C. obtain a prescription for enoxaparin
- D. monitor renal function
Correct Answer: D
Rationale: Infective endocarditis can cause glomerulonephritis, necessitating renal function monitoring (e.g., creatinine levels).