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Sublingual nitroglycerin is administered to a male client with unstable angina who complains of crushing chest pain. Five minutes later, the client becomes nauseated, and his blood pressure drops to 60/40 mm Hg. Which intervention should the nurse implement?
- A. Administer a second dose of nitroglycerin.
- B. Infuse a rapid IV normal saline bolus.
- C. Begin external chest compressions.
- D. Give a PRN antiemetic medication.
Correct Answer: B
Rationale: The correct intervention in this situation is to infuse a rapid IV normal saline bolus. The client's drop in blood pressure to 60/40 mm Hg after nitroglycerin administration indicates hypotension, which may suggest a right ventricular infarction. Normal saline bolus helps to increase intravascular volume, improve cardiac output, and support blood pressure. Administering a second dose of nitroglycerin would further decrease blood pressure. External chest compressions are not indicated as the client's heart is still beating, and there is no indication for CPR. Giving an antiemetic medication is not the priority in this situation where hypotension is the main concern.
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A client with a history of congestive heart failure is admitted with shortness of breath. Which nursing intervention should the nurse implement first?
- A. Elevate the head of the bed.
- B. Administer prescribed diuretic therapy.
- C. Monitor the client's oxygen saturation.
- D. Assess the client's level of consciousness.
Correct Answer: A
Rationale: The correct answer is to elevate the head of the bed. Elevating the head of the bed is crucial in improving oxygenation in clients with congestive heart failure and shortness of breath by reducing venous return to the heart and decreasing fluid overload in the lungs. This intervention helps to alleviate the client's breathing difficulty. Administering diuretic therapy (Choice B) may be necessary but is not the initial priority. Monitoring oxygen saturation (Choice C) is important but should come after ensuring proper positioning. Assessing the client's level of consciousness (Choice D) is essential but is not the first intervention needed for a client experiencing respiratory distress.
A nurse plans to call the healthcare provider to report an 0600 serum potassium level of 2 mEq/L or mmol/L (SI), but the charge nurse tells the nurse that the healthcare provider does not like to receive early morning calls and will make rounds later in the morning. What action should the nurse take?
- A. Contact the healthcare provider immediately to report the laboratory value regardless of the advice.
- B. Document the finding and report it when the healthcare provider makes rounds.
- C. Notify the charge nurse that you are following the chain of command.
- D. Administer a potassium supplement and notify the provider later.
Correct Answer: A
Rationale: A nurse should contact the healthcare provider immediately to report a critically low potassium level of 2 mEq/L. Potassium levels below the normal range can lead to life-threatening complications such as cardiac arrhythmias. Prompt notification is essential to ensure timely intervention and prevent harm to the patient. Option B is incorrect as delaying reporting such a critical value can jeopardize patient safety. Option C is not the priority in this situation; the focus should be on patient care. Option D is dangerous and inappropriate as administering a potassium supplement without healthcare provider's guidance can be harmful, especially with a critically low level.
A client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which laboratory value should be closely monitored before the procedure?
- A. Serum creatinine of 2.0 mg/dl
- B. Serum potassium of 5.5 mEq/L
- C. Serum calcium of 8.0 mg/dl
- D. Hemoglobin of 12 g/dl
Correct Answer: B
Rationale: A serum potassium level of 5.5 mEq/L is concerning in a client with ESRD scheduled for hemodialysis as it indicates hyperkalemia, which can lead to serious cardiac complications. Hyperkalemia can be exacerbated during hemodialysis, making it crucial to closely monitor serum potassium levels before the procedure. Monitoring serum creatinine, serum calcium, or hemoglobin levels is important in managing ESRD but is not the immediate focus before hemodialysis. Therefore, option B is the correct choice.
A client with heart failure is receiving digoxin (Lanoxin) and furosemide (Lasix). Which assessment finding requires immediate intervention?
- A. Heart rate of 60 beats per minute
- B. Apical pulse of 58 beats per minute
- C. Presence of a new murmur
- D. Blood pressure of 100/60 mmHg
Correct Answer: C
Rationale: The correct answer is C. The presence of a new murmur in a client with heart failure receiving digoxin and furosemide is concerning as it may indicate valvular problems or other complications that require immediate intervention. A heart rate of 60 beats per minute and an apical pulse of 58 beats per minute are within normal limits for a client with heart failure on these medications. A blood pressure of 100/60 mmHg, while slightly low, may be expected due to the diuretic effect of furosemide and may not require immediate intervention unless the client is symptomatic.
A client with liver cirrhosis is admitted with ascites and jaundice. Which assessment finding is most concerning?
- A. Serum albumin of 3.0 g/dL
- B. Bilirubin of 3.0 mg/dL
- C. Ammonia level of 80 mcg/dL
- D. Prothrombin time of 18 seconds
Correct Answer: C
Rationale: An ammonia level of 80 mcg/dL is elevated and concerning in a client with liver cirrhosis, as it may indicate hepatic encephalopathy. Elevated ammonia levels can lead to cognitive impairment, altered mental status, and even coma. Serum albumin, bilirubin, and prothrombin time are also important markers in liver cirrhosis but are not as directly associated with the risk of hepatic encephalopathy as elevated ammonia levels.