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A nurse is assessing the patient's home medication use. After listening to the patient's list of current medications, the nurse asks what priority query?
- A. Do you take any generic medications?
- B. Do you take over-the-counter medication?
- C. Are these medications safe to take during pregnancy?
- D. Are any of these medications orphan drugs?
Correct Answer: B
Rationale: The correct answer is B: "Do you take over-the-counter medication?" This is the priority query because over-the-counter medications may interact with prescription drugs, leading to adverse effects. It is crucial for the nurse to assess all medications the patient is taking, including over-the-counter ones, to ensure safety and effectiveness of the overall treatment plan.
Choice A is incorrect because whether the medications are generic or brand name does not directly impact safety or interactions. Choice C is incorrect as it assumes pregnancy, which may not be relevant to the patient. Choice D is incorrect as orphan drugs are not commonly used and not a priority in this context.
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A patient diagnosed with Heart Failure would like the nurse to explain what the diagnosis means. How will the nurse explain heart failure?
- A. The heart muscle cannot pump effectively, causing a backup of blood.
- B. Increased protein leads to reduced oncotic pressure and inability to pull the fluid into the system.
- C. The hydrostatic pressure pushing fluids out of the capillary is lower than the oncotic pressure.
- D. The decrease in venous pressure from the backup of blood increases hydrostatic pressure.
Correct Answer: A
Rationale: The correct answer is A: The heart muscle cannot pump effectively, causing a backup of blood. This is the most accurate explanation of heart failure. In heart failure, the heart is unable to pump blood efficiently, leading to a backup of blood in the circulatory system. This can result in symptoms such as shortness of breath, fatigue, and fluid retention.
Explanation for why the other choices are incorrect:
B: Increased protein leading to reduced oncotic pressure is not a direct cause of heart failure.
C: This choice describes the forces involved in fluid movement, not the primary mechanism of heart failure.
D: Heart failure causes a backup of blood, which in turn increases venous pressure, not the other way around.
In summary, choice A is correct as it directly addresses the primary issue of heart failure, while the other choices focus on different physiological processes not directly related to heart failure.
What is the responsibility of the nurse related to the patient's drug therapy? Select all that apply.
- A. Teaching the patient how to cope with therapy to ensure the best outcome.
- B. Altering the drug regime to optimize the outcome.
- C. Evaluating the effectiveness of therapy.
- D. Providing therapy as well as medications.
- E. Recommending over-the-counter medications to treat adverse effects of prescription drug therapy.
Correct Answer: A,C
Rationale: The correct answers are A and C. A nurse's responsibility related to a patient's drug therapy includes teaching the patient how to cope with therapy for optimal outcomes (A) and evaluating the effectiveness of the therapy (C). Teaching the patient ensures they understand how to take medications correctly and manage any side effects. Evaluating effectiveness allows for adjustments in the treatment plan if needed. Choices B, D, and E are incorrect. B - altering the drug regime should be done by the prescribing healthcare provider, not the nurse. D - providing therapy is beyond the scope of a nurse's responsibilities, as they focus on administering medications and supporting the patient. E - recommending over-the-counter medications falls under the purview of a pharmacist or physician, not a nurse.
The nurse is preparing to care for a patient who has myasthenia gravis. The nurse will be alert to symptoms affecting which body system in the patient?
- A. Gastrointestinal (GI) and lower extremity muscles.
- B. Central nervous system (CNS), memory, and cognition.
- C. Respiratory and facial muscles.
- D. Cardiovascular system and postural muscles.
Correct Answer: C
Rationale: The correct answer is C: Respiratory and facial muscles. Myasthenia gravis is an autoimmune disorder that affects the neuromuscular junction, leading to muscle weakness and fatigue. Symptoms commonly affect muscles involved in breathing (respiratory) and facial expressions, such as difficulty swallowing, breathing, speaking, and facial drooping. Monitoring these systems is crucial as respiratory muscle weakness can lead to respiratory failure. Choice A is incorrect because myasthenia gravis does not typically affect gastrointestinal or lower extremity muscles primarily. Choice B is incorrect as the primary symptoms of myasthenia gravis do not involve the central nervous system but rather the neuromuscular junction. Choice D is incorrect as myasthenia gravis does not directly impact the cardiovascular system or postural muscles.
Ask the nurse to explain the type of angina he is experiencing. The nurse explains the pain is due to the imbalance of myocardial supply.
- A. Unstable.
- B. Ischemic.
- C. Stable angina.
- D. Prinzmetal.
Correct Answer: C
Rationale: The correct answer is C: Stable angina. This type of angina occurs due to a predictable pattern of exertional activities causing chest pain. The imbalance in myocardial supply and demand is typically relieved with rest or medication. Unstable angina (A) is characterized by unpredictable chest pain at rest or with minimal exertion, indicating a more severe condition. Ischemic (B) refers to inadequate blood flow to the heart muscle, which can lead to angina. Prinzmetal angina (D) is caused by coronary artery spasm rather than exertion, making it less likely in this scenario.
The nurse is preparing to assist with blood collection on a newly admitted patient who has been taking phenytoin for several years. The provider has ordered a complete blood count and liver function tests. Which other blood test will the nurse discuss with the provider?
- A. Coagulation studies.
- B. Serum electrolytes.
- C. Renal function tests.
- D. Blood glucose.
Correct Answer: D
Rationale: The correct answer is D: Blood glucose. Phenytoin can potentially affect blood glucose levels by causing hyperglycemia. Monitoring blood glucose levels is important to ensure the patient's safety and adjust medication dosages if needed.
Other choices are incorrect:
A: Coagulation studies are not typically affected by phenytoin therapy.
B: Serum electrolytes may need monitoring for other reasons, but not specifically related to phenytoin use.
C: Renal function tests are important for monitoring kidney function but are not directly influenced by phenytoin.