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An outcome for treatment of peripheral vascular disease is, 'The client will have decreased venous congestion.' What client behavior would indicate to the nurse that this outcome has been met?
- A. Avoids prolonged sitting or standing.
- B. Avoids trauma and irritation to skin.
- C. Wears protective shoes.
- D. Quits smoking.
Correct Answer: A
Rationale: The correct answer is A because avoiding prolonged sitting or standing helps improve venous return by preventing blood from pooling in the legs, reducing venous congestion. This behavior promotes circulation and decreases the risk of complications. Choices B, C, and D do not directly address venous congestion or circulation improvement, making them incorrect options. Avoiding trauma and irritation to the skin (B) is important for skin integrity but not specifically for venous congestion. Wearing protective shoes (C) is related to preventing foot injuries but does not directly impact venous congestion. Quitting smoking (D) is beneficial for overall health but does not directly target venous congestion.
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A patient with chronic heart failure is prescribed carvedilol. What is the primary purpose of this medication?
- A. Increase cardiac output
- B. Reduce fluid retention
- C. Decrease heart rate
- D. Lower blood pressure
Correct Answer: C
Rationale: The correct answer is C: Decrease heart rate. Carvedilol is a beta-blocker that works by blocking the beta-adrenergic receptors in the heart, leading to a decrease in heart rate. This helps reduce the workload of the heart and improve its efficiency in patients with heart failure. Choice A is incorrect because carvedilol may not necessarily increase cardiac output directly. Choice B is incorrect because carvedilol focuses more on improving heart function rather than directly reducing fluid retention. Choice D is incorrect because while carvedilol may lower blood pressure as a secondary effect, its primary purpose in heart failure is to improve cardiac function by decreasing heart rate.
A patient with epilepsy is prescribed phenytoin. What is the primary side effect the nurse should monitor for?
- A. Hypotension
- B. Gingival hyperplasia
- C. Bradycardia
- D. Hyperkalemia
Correct Answer: B
Rationale: The correct answer is B: Gingival hyperplasia. Phenytoin is known to cause gingival overgrowth as a side effect. This is due to its effect on fibroblasts in the gums, leading to increased connective tissue production. Hypotension (A), bradycardia (C), and hyperkalemia (D) are not common side effects of phenytoin. Monitoring for gingival hyperplasia is crucial to prevent complications such as difficulty in eating, speaking, and maintaining oral hygiene.
A patient with severe pain is prescribed morphine sulfate. What is the most important side effect for the nurse to monitor?
- A. Diarrhea
- B. Hypertension
- C. Respiratory depression
- D. Increased urine output
Correct Answer: C
Rationale: The correct answer is C: Respiratory depression. Morphine sulfate is an opioid analgesic that can suppress the respiratory drive, leading to respiratory depression, which can be life-threatening. Monitoring respiratory status is crucial to prevent complications.
Incorrect choices:
A: Diarrhea - While constipation is a common side effect of opioid use, diarrhea is not a significant concern compared to respiratory depression.
B: Hypertension - Morphine can cause hypotension rather than hypertension, so monitoring blood pressure for hypertension is not the priority.
D: Increased urine output - Morphine can actually cause urinary retention, so increased urine output is not a key side effect to monitor.
A client is being discharged with a new prescription for enoxaparin (Lovenox). Which instruction should the nurse include?
- A. Administer the injection in your thigh.
- B. Do not expel the air bubble from the syringe before injection.
- C. Massage the injection site after administration.
- D. Alternate the injection site between the arms.
Correct Answer: B
Rationale: The correct answer is B because expelling the air bubble from the syringe before injection helps ensure accurate dosage delivery and prevents air from being injected into the patient. Administering the injection in the thigh (A) is incorrect as enoxaparin is typically given in the abdomen. Massaging the injection site (C) can cause bruising or hematoma formation. Alternating injection sites between arms (D) is not relevant as enoxaparin is usually given in the abdomen.
A patient with depression is prescribed fluoxetine. What is an important side effect for the nurse to monitor?
- A. Weight gain
- B. Bradycardia
- C. Dry mouth
- D. Suicidal thoughts
Correct Answer: D
Rationale: The correct answer is D: Suicidal thoughts. When a patient with depression is prescribed fluoxetine, there is a risk of increased suicidal thoughts, especially in the initial weeks of treatment. This is important for the nurse to monitor because it can lead to serious consequences. Weight gain (A) is a common side effect of fluoxetine but not as critical to monitor as suicidal thoughts. Bradycardia (B) and dry mouth (C) are not common side effects of fluoxetine and are less relevant to monitor in this scenario. Monitoring for suicidal thoughts is crucial for patient safety.