Nokea
A continuous infusion of nitroglycerin is prescribed for an adult male admitted with an acute myocardial infarction. The client is experiencing active chest pain that he describes as 8 out of 10. Which intervention is most important for the nurse to implement?
- A. Administer the infusion via an infusion pump
- B. Obtain the current serum potassium level
- C. Continuously monitor blood pressure
- D. Teach guided imagery to decrease pain
Correct Answer: C
Rationale: Continuously monitoring blood pressure is crucial in this case because nitroglycerin can cause hypotension as a side effect. Monitoring blood pressure allows the nurse to assess the client's response to the medication and detect any signs of hypotension promptly. This intervention is essential to ensure the effectiveness of nitroglycerin therapy and prevent potential complications. Administering the infusion via an infusion pump is important for accurate dosing but not the most critical at this moment. Obtaining the current serum potassium level is important but not the most immediate concern when the client is experiencing active chest pain. Teaching guided imagery may be beneficial for pain management, but in this scenario, monitoring blood pressure takes precedence due to the potential side effects of nitroglycerin.
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A male client with diabetes mellitus takes NPH/regular 70/30 insulin before meals and azithromycin PO daily, using medication he brought from home. When the nurse delivers his breakfast tray, the client tells the nurse that he took his insulin but forgot to take his daily dose of azithromycin an hour before breakfast as instructed. What action should the nurse implement?
- A. Provide a PRN dose of an antacid to take with the azithromycin right after breakfast
- B. Offer to obtain a new breakfast tray in an hour so the client can take the azithromycin
- C. Instruct the client to eat his breakfast and take the azithromycin two hours after eating
- D. Tell the client to skip that day's dose and resume taking the azithromycin the next day
Correct Answer: C
Rationale: Azithromycin should ideally be taken on an empty stomach; however, if taken after breakfast, it should not affect its efficacy. Instructing the client to eat his breakfast and take the azithromycin two hours after eating allows for proper absorption without compromising its effectiveness. Providing an antacid with azithromycin is not necessary in this case. Offering a new breakfast tray in an hour or skipping the dose is not the best course of action as it may lead to missed doses and potential effectiveness issues.
The nurse is providing discharge teaching to a client who has undergone abdominal surgery. What instruction should the nurse include?
- A. Avoid heavy lifting for at least 6 weeks
- B. Limit fluid intake to reduce the risk of infection
- C. Resume normal activities as soon as possible
- D. Avoid driving for at least 2 weeks
Correct Answer: A
Rationale: The correct answer is A: 'Avoid heavy lifting for at least 6 weeks.' After abdominal surgery, it is essential to avoid heavy lifting to prevent complications such as incisional hernias and support proper healing. Choice B, 'Limit fluid intake to reduce the risk of infection,' is incorrect because adequate fluid intake is necessary for wound healing and preventing dehydration. Choice C, 'Resume normal activities as soon as possible,' is incorrect as it may increase the risk of complications and delay healing. Choice D, 'Avoid driving for at least 2 weeks,' is incorrect as the restriction on driving may vary depending on the type of surgery and individual recovery.
A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of 25,000/mm3. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Monitor for signs of activity intolerance
- B. Require visitors to wear respiratory masks
- C. Assess urine and stool for occult blood
- D. Obtain client's temperature q4 hours
Correct Answer: C
Rationale: The correct answer is to assess urine and stool for occult blood. With a low platelet count, there is an increased risk of bleeding. Monitoring for occult blood is essential to detect any signs of internal bleeding. Choices A, B, and D are not the priority interventions in this situation. While monitoring for signs of activity intolerance, requiring visitors to wear respiratory masks, and obtaining the client's temperature are important aspects of care, they are not as critical as assessing for occult blood in a client with a low platelet count.
After medicating the client for pain and collecting granules and stones from strained urine, which action is most important for the nurse to implement next?
- A. Send the calculi for laboratory analysis of stone composition.
- B. Evaluate the client for persistent pain.
- C. Assess the clarity of urine.
- D. Encourage high fluid intake to produce urine output of 2L/day.
Correct Answer: A
Rationale: Sending the calculi for analysis is crucial in determining the type of stone present. Identifying the stone composition helps in developing an effective treatment plan and preventive measures to avoid future episodes of urolithiasis. This step is essential in providing targeted care for the client. Options B, C, and D are not the most important actions at this point. While evaluating for persistent pain is essential, determining the stone composition takes precedence to guide appropriate interventions.
The client has silvery scaling plaques bilaterally on elbows, forearms, and palms. When scratched, the skin bleeds over these plaques. What is most important to include in this client's plan of care?
- A. Interventions to decrease emotional stress
- B. Precautions about avoiding sunlight
- C. Strategies to increase omega-3 fatty acids in the diet
- D. Instruct about applying a corticosteroid cream
Correct Answer: A
Rationale: The most important aspect to include in this client's plan of care is interventions to decrease emotional stress. Psoriasis, characterized by silvery scaling plaques on the skin, can be exacerbated by emotional stress. Managing stress is crucial in controlling the condition. Precautions about avoiding sunlight are important in psoriasis management, but emotional stress has a more significant impact. While omega-3 fatty acids may provide some benefits, stress management should take priority. Applying a corticosteroid cream may help with symptoms, but addressing emotional stress is crucial for long-term management of psoriasis.