Nokea
A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care service. What interventions should the nurse include to the home health nurse upon discharge?
- A. Medication reconciliation
- B. Immunization history
- C. Medication history
- D. Nutrition preferences
Correct Answer: A
Rationale: The home health nurse needs to know current medications the client is taking to ensure assessment, evaluation, and further education related to these medications. The other information will not assist the nurse to develop a plan of care for the client.
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A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this clients teaching? (Select all that apply.)
- A. Smoking cessation
- B. Stress relaxation and management
- C. Avoiding vagal stimulation
- D. Adverse effects of medications
- E. Foods high in potassium
Correct Answer: A,B,D
Rationale: A client who has premature beats or ectopic rhythms should be taught to stop smoking, manage stress, take medications as prescribed, and report adverse effects of medications. Clients with premature beats are not at risk for vasovagal attacks or potassium imbalances.
The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, Why do you want to know if you is cause? How should the nurse respond?
- A. Substance abuse puts clients at risk for many health issues
- B. The hospital requires that I ask you about cocaine use
- C. Clients who use cocaine or illicit inhalants are particularly at risk for potentially fatal dysrhythmias
- D. We can provide services for cessation of substance abuse
Correct Answer: C
Rationale: Clients who use cocaine or illicit inhalants are particularly at risk for potentially fatal dysrhythmias. The other responses do not adequately address the client's question.
After assessing a client who is receiving an amiodarone intravenous infusion for unstable ventricular tachycardia, the nurse documents the findings and compares these with the previous assessment findings: [Vital signs data]. Based on the assessments, which action should the nurse take?
- A. Stop the infusion and flush the IV
- B. Slow the amiodarone infusion rate
- C. Administer IV normal saline
- D. Ask the client to cough and deep breathe
Correct Answer: B
Rationale: IV administration of amiodarone may cause bradycardia and atrioventricular (AV) block. The correct action for the nurse to take at this time is to slow the infusion, because the client is asymptomatic and no evidence reveals AV block that might require pacing. Abruptly stopping the medication could allow fatal dysrhythmias to occur.
A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this clients concerns?
- A. Administer oxygen therapy at 2 liters per nasal cannula
- B. Provide a sleeping aid prior to bedtime
- C. Schedule periods of exercise and rest during the day
- D. Ask unlicensed assistive personnel to help bathe the client
Correct Answer: C
Rationale: Clients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse should schedule periods of exercise and rest during the day to decrease fatigue when completing activities of daily living. The client should be encouraged to participate in self-care activities.
A nurse performs an admission assessment on a 75-year-old client with multiple chronic diseases. The clients blood pressure is 155/75 mm Hg and oxygen saturation is [missing data].
- A. Assess current medications
- B. Check oxygen saturation
- C. Evaluate dietary habits
- D. Review immunization history
Correct Answer: A
Rationale: The client is on multiple medications that can interact with each other. The nurse should assess the client's current medications first to identify potential interactions that could contribute to cardiac dysrhythmias or other complications.