Nokea
A client who had a myocardial infarction (MI) two days ago reports chest pain radiating to the left arm. What should the nurse do immediately?
- A. Administer morphine
- B. Obtain an electrocardiogram (ECG)
- C. Apply oxygen via nasal cannula
- D. Administer sublingual nitroglycerin
Correct Answer: B
Rationale: Obtaining an ECG is crucial in this situation because it helps in assessing for potential complications, such as a recurrent MI or ongoing ischemia. This diagnostic test provides valuable information to guide further interventions and treatment. Administering morphine, oxygen, or nitroglycerin may be necessary but obtaining an ECG takes precedence to evaluate the cardiac status and determine the appropriate course of action.
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In monitoring the effectiveness of warfarin therapy for a client with a history of atrial fibrillation, which laboratory value should the nurse monitor?
- A. Activated partial thromboplastin time (aPTT)
- B. Prothrombin time (PT) and international normalized ratio (INR)
- C. Platelet count
- D. Erythrocyte sedimentation rate (ESR)
Correct Answer: B
Rationale: Prothrombin time (PT) and international normalized ratio (INR) are crucial laboratory values to monitor the effectiveness of warfarin therapy in clients with atrial fibrillation. These values help ensure that the client is within the therapeutic range and that the anticoagulant effect of warfarin is appropriate.
The nurse is caring for a client who has undergone a coronary artery bypass graft (CABG) surgery. Which action should the nurse take to prevent postoperative complications?
- A. Encourage the client to cough and deep breathe every 1 to 2 hours.
- B. Maintain the client in a supine position at all times.
- C. Keep the client on bed rest for the first 48 hours.
- D. Restrict the client's fluid intake to prevent overload.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client has a new prescription for rifampin. Which of the following instructions should the nurse include?
- A. Take the medication with food.
- B. Expect red-orange discoloration of body fluids.
- C. Monitor for signs of hyperglycemia.
- D. Avoid consuming dairy products.
Correct Answer: B
Rationale: The correct answer is to inform the client to expect red-orange discoloration of body fluids when taking rifampin. This side effect is harmless but can be surprising to patients. It is important for the nurse to educate the client about this expected change to prevent unnecessary concern or alarm. Monitoring for hyperglycemia is not directly related to rifampin, and taking the medication with food or avoiding dairy products are not specific instructions for this medication.
A client with a history of heart failure is prescribed metoprolol (Lopressor). The nurse should monitor the client for which common side effect of this medication?
- A. Tachycardia
- B. Hypotension
- C. Hypertension
- D. Hyperglycemia
Correct Answer: B
Rationale: Metoprolol is a beta-blocker commonly used in heart failure to reduce blood pressure. One of the common side effects of metoprolol is hypotension, which can lead to dizziness, lightheadedness, and even fainting. Therefore, monitoring for hypotension is essential to prevent adverse effects and ensure patient safety.
A client is scheduled for a coronary artery bypass graft (CABG) surgery. The nurse should prepare the client by reinforcing information about which post-operative care measure?
- A. You will be on bed rest for the first 48 hours after surgery.
- B. You will be encouraged to cough and deep breathe frequently.
- C. You will be discharged within 24 hours if no complications arise.
- D. You will not be able to eat or drink for 24 hours after surgery.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.