Nokea
During a home visit to an 88-year-old patient who is taking digoxin (Lanoxin) 0.25 mg daily to help control the rate of atrial fibrillation, you obtain this assessment information. Which assessment indicates that you need to notify the physician?
- A. The patient's apical pulse is 68 and very irregular.
- B. The patient takes the digoxin with meals.
- C. The patient's vision is becoming 'fuzzy'.
- D. The patient has lung crackles that clear after coughing.
Correct Answer: C
Rationale: Visual disturbances can indicate digoxin toxicity, necessitating physician notification.
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Which of the following should the nurse identify as the earliest symptom of heart failure in many older clients?
- A. Increased urine output
- B. Swollen joints
- C. Dyspnea on exertion
- D. Nausea and vomiting
Correct Answer: C
Rationale: Dyspnea on exertion is often the first noticeable symptom of heart failure due to reduced cardiac output and pulmonary congestion.
The client on amiodarone reports shortness of breath. What is the nurse's best response?
- A. Notify the healthcare provider immediately.
- B. Reassure the client that this is a common side effect.
- C. Instruct the client to monitor their symptoms at home.
- D. Suggest the client reduce physical activity.
Correct Answer: A
Rationale: The correct answer is A: Notify the healthcare provider immediately. Shortness of breath in a client on amiodarone can indicate a serious side effect such as pulmonary toxicity or interstitial lung disease. The nurse should prioritize the client's safety by promptly informing the healthcare provider for further evaluation and management. This is crucial to prevent potential harm or worsening of the condition.
Summary:
- Choice B is incorrect because shortness of breath with amiodarone is not a common side effect to be reassured about.
- Choice C is incorrect as monitoring symptoms at home may delay necessary medical intervention.
- Choice D is incorrect as reducing physical activity does not address the potential serious side effect of amiodarone.
If Mrs. Jones has a temporary pacemaker and the pacemaker intermittently fails to capture or sense, increasing the output temporarily restores function. Failure to capture or sense appropriately is most often due to
- A. Prior emergency defibrillation for ventricular failure
- B. Dislodgment of pacing electrode from right ventricle
- C. Occurrence of frequent ectopic beats from right ventricle
- D. Perforation to the right ventricle by pacing electrode
Correct Answer: B
Rationale: Dislodgment affects proper pacemaker function.
What is a condition where blood clots form in the deep veins, usually in the legs, and can travel to the lungs, causing serious complications?
- A. Deep vein thrombosis (DVT)
- B. Pulmonary embolism
- C. Varicose veins
- D. Peripheral artery disease
Correct Answer: A
Rationale: The correct answer is A: Deep vein thrombosis (DVT). DVT is a condition where blood clots form in the deep veins, typically in the legs. These clots can dislodge and travel to the lungs, leading to a pulmonary embolism. Choice B, pulmonary embolism, is a complication of DVT, not the initial condition. Varicose veins (C) are enlarged, twisted veins usually visible on the skin surface, not deep veins. Peripheral artery disease (D) involves narrowed arteries, not blood clots in veins.
To detect and treat the most common complication of MI, what should the nurse do?
- A. Measure hourly urine output
- B. Auscultate the chest for crackles
- C. Use continuous cardiac monitoring
- D. Take vital signs every 2 hours for the first 8 hours
Correct Answer: C
Rationale: Continuous monitoring detects dysrhythmias.