Nokea
The following scenario applies to the next 1 items
The nurse in the intensive care unit (ICU) is caring for 58-year-old male client
Item 1 of 1
Medical History Vital Signs Medication Administration Record
• atrial fibrillation
• chronic obstructive pulmonary disease
• hyperlipidemia
• chronic back pain
Based on the 2000 vital signs, select two (2) immediate actions the nurse should take for a client with atrial fibrillation, COPD, hyperlipidemia, and chronic back pain.
- A. Stop the diltiazem infusion
- B. Apply supplemental oxygen via nonrebreather face mask
- C. Stop the 0.9% saline infusion
- D. Notify the primary healthcare provider
- E. Assess the client for back pain
- F. Request a prescription to change the intravenous fluids to hypertonic saline
Correct Answer: B,D
Rationale: Supplemental oxygen addresses potential hypoxia from COPD or atrial fibrillation complications. D: Correct - Notifying the provider ensures timely management of abnormal vital signs. A, C, E, F: Incorrect - No vital sign data suggests stopping infusions, assessing back pain, or changing to hypertonic saline.
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Which of the following interventions should the nurse include when teaching clients strategies for preventing cardiovascular disease? Select all that apply.
- A. Encouraging regular physical exercise
- B. Promoting a diet high in saturated fats
- C. Advising smoking cessation
- D. Recommend no more than 5 alcoholic drinks a day
- E. Educating about the importance of regular blood pressure monitoring
- F. Instructing on the importance of regular cholesterol screenings
Correct Answer: A,C,E,F
Rationale: Regular exercise reduces cardiovascular risk. B: Incorrect - High saturated fat diets increase cardiovascular risk. C: Correct - Smoking cessation lowers cardiovascular disease risk. D: Incorrect - Alcohol should be limited to 1-2 drinks per day for men, 1 for women. E: Correct - Blood pressure monitoring detects hypertension early. F: Correct - Cholesterol screenings identify hyperlipidemia for early intervention.
The nurse caring for a client with a history of atrial fibrillation is prescribed dofetilide to control the dysrhythmia. What assessment should the nurse prioritize before administering the medication?
- A. Daily weight
- B. Liver function tests
- C. QT interval on the electrocardiogram (ECG)
- D. Blood urea nitrogen (BUN) and creatinine levels
Correct Answer: C
Rationale: Dofetilide can prolong the QT interval, increasing the risk of torsades de pointes, so monitoring the ECG for QT prolongation is critical.
A hypertensive client was prescribed antihypertensive medication. The client tells a clinic nurse that she prefers to take an herbal supplement to help lower her blood pressure. Which is the most appropriate response from the nurse?
- A. Tell the client that herbal supplements are unsafe and should be avoided
- B. Encourage the client to discuss the use of herbal supplements with her attending health care provider (HCP)
- C. Teach the client how to take her blood pressure and ask her to monitor it every fifteen minutes
- D. Tell the client that if she takes the herbal supplement, it will require the nurses to monitor her blood pressure closely
Correct Answer: B
Rationale: Herbal supplements can interact with medications, so discussing with the HCP ensures safety and efficacy.
The nurse is caring for a client with congestive heart failure experiencing an exacerbation. Which of the following of the client's vital signs would indicate that the client is experiencing a complication?
- A. Decrease in blood pressure
- B. Increase in temperature
- C. Decrease in respiratory rate
- D. Increase in blood pressure
Correct Answer: A
Rationale: A decrease in blood pressure during a CHF exacerbation may indicate cardiogenic shock, a serious complication.
Which of the following would be an expected finding in a client with infective endocarditis (IE)? Select all that apply.
- A. Fever
- B. Night sweats
- C. Osler nodes
- D. Cardiac murmur
- E. Syncope
- F. Weight loss
Correct Answer: A,B,C,D,F
Rationale: Fever is common due to infection. Night sweats are a systemic symptom of IE. C: Correct - Osler nodes are painful nodules associated with IE. D: Correct - Cardiac murmur results from valve involvement. E: Incorrect - Syncope is not a hallmark of IE. F: Correct - Weight loss occurs due to chronic infection.