Nokea
The client is on spironolactone (Aldactone). What is the most important dietary instruction?
- A. Avoid foods high in potassium.
- B. Increase intake of foods high in potassium.
- C. Avoid foods high in sodium.
- D. Increase intake of foods high in sodium.
Correct Answer: A
Rationale: The correct answer is A: Avoid foods high in potassium. Spironolactone is a potassium-sparing diuretic that can increase potassium levels in the body. Consuming foods high in potassium while on spironolactone can lead to hyperkalemia, which can be dangerous. By avoiding foods high in potassium, the client can help maintain a safe potassium level.
Summary:
- Choice B (Increase intake of foods high in potassium) is incorrect because it can lead to hyperkalemia when combined with spironolactone.
- Choice C (Avoid foods high in sodium) is unrelated to spironolactone's mechanism of action.
- Choice D (Increase intake of foods high in sodium) is incorrect as it is not relevant to the dietary instruction needed for a client on spironolactone.
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In the patient with chest pain, which results can differentiate unstable angina from an MI?
- A. ECG changes present at the onset of the pain
- B. A chest x-ray indicating left ventricular hypertrophy
- C. Appearance of troponin in the blood 48 hours after the infarct
- D. Creatine kinase (CK)-MB enzyme elevations that peak 18 hours after the infarct
Correct Answer: A
Rationale: ECG changes distinguish unstable angina from MI.
The client is on nitroglycerin patches. What should the nurse include in the client's education?
- A. Rotate the application site with each new patch.
- B. Apply the patch at the same time each day.
- C. Leave the patch on for 24 hours, then remove it for 12 hours before applying a new one.
- D. Apply the patch to the same site each time.
Correct Answer: A
Rationale: The correct answer is A: Rotate the application site with each new patch. This is important to prevent skin irritation and tolerance development. Rotating sites ensures consistent drug absorption and reduces the risk of skin reactions. Applying the patch at the same site each time (choice D) can lead to localized skin irritation. Applying the patch at the same time each day (choice B) is not as crucial as rotating sites. Leaving the patch on for 24 hours and then removing it for 12 hours (choice C) can disrupt the therapeutic effect of the medication.
The client on warfarin has an INR of 3.8. What is the most appropriate action by the nurse?
- A. Administer vitamin K.
- B. Hold the next dose of warfarin.
- C. Increase the dose of warfarin.
- D. Notify the healthcare provider immediately.
Correct Answer: A
Rationale: The correct answer is A: Administer vitamin K. When a client on warfarin has an INR above the therapeutic range (usually 2-3), like in this case (3.8), administering vitamin K is appropriate to reverse the anticoagulant effects. This helps prevent bleeding complications. Holding the next dose of warfarin (B) may not be sufficient to lower the INR quickly. Increasing the dose of warfarin (C) would further elevate the INR, leading to higher bleeding risk. Notifying the healthcare provider (D) is important, but immediate action with vitamin K is necessary to address the high INR.
What is a condition where the heart's ability to pump blood is reduced because the heart muscle is enlarged, thickened, or stiffened?
- A. Cardiomyopathy
- B. Endocarditis
- C. Myocarditis
- D. Aortic stenosis
Correct Answer: A
Rationale: The correct answer is A: Cardiomyopathy. Cardiomyopathy refers to a condition where the heart muscle is enlarged, thickened, or stiffened, leading to a reduced ability to pump blood effectively. This condition directly relates to the heart's structural changes, impacting its pumping function. Endocarditis (B) is an infection of the heart's inner lining, not directly related to heart muscle changes. Myocarditis (C) is inflammation of the heart muscle but does not necessarily involve structural changes leading to reduced pumping ability. Aortic stenosis (D) is a condition where the heart's aortic valve is narrowed, impeding blood flow, but it does not specifically refer to the heart muscle changes seen in cardiomyopathy.
Which valve opens during ventricular systole and closes during ventricular diastole?
- A. Aortic valve
- B. Pulmonary valve
- C. Mitral valve
- D. Tricuspid valve
Correct Answer: B
Rationale: During ventricular systole, the ventricles contract to pump blood out. The pulmonary valve opens to allow blood to be ejected from the right ventricle into the pulmonary artery, leading to the lungs. This prevents the backflow of blood into the right ventricle during ventricular diastole when the ventricles relax. The aortic valve opens during ventricular systole to allow blood to be ejected from the left ventricle into the aorta, not during ventricular diastole. The mitral valve and tricuspid valve control the flow of blood between the atria and ventricles, not during ventricular systole. Therefore, the correct answer is B (Pulmonary valve).