Nokea
The client is receiving digoxin and complains of nausea. What is the nurse's priority action?
- A. Check the client's digoxin level.
- B. Continue the current dose of digoxin.
- C. Administer an antiemetic for nausea.
- D. Discontinue the digoxin immediately.
Correct Answer: A
Rationale: The correct answer is A: Check the client's digoxin level. The priority action is to assess the digoxin level to determine if it is within the therapeutic range, as nausea can be a sign of digoxin toxicity. Checking the level will guide further actions. Continuing the dose without assessment (B) may worsen toxicity. Administering an antiemetic (C) only addresses the symptom, not the underlying cause. Discontinuing digoxin immediately (D) without assessing the level can be harmful if the client actually needs the medication.
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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).
What is a condition where a blood clot forms in a vein, often in the legs, which can cause pain and swelling and may lead to serious complications if it travels to the lungs?
- A. Deep vein thrombosis (DVT)
- B. Pulmonary embolism
- C. Varicose veins
- D. Aneurysm
Correct Answer: A
Rationale: The correct answer is A: Deep vein thrombosis (DVT). DVT occurs when a blood clot forms in a deep vein, often in the legs. This can cause pain, swelling, and potentially serious complications if the clot dislodges and travels to the lungs, leading to a pulmonary embolism. Varicose veins (C) are enlarged, twisted veins close to the skin's surface, not deep veins. Aneurysm (D) is the ballooning of a blood vessel, not a clot formation. Pulmonary embolism (B) is a complication of DVT, not the initial condition.
During hemodynamic monitoring, the nurse finds that the patient has a decreased CO with unchanged pulmonary artery wedge pressures, HR, and SVR. The nurse identifies that the patient has a decrease in
- A. SV
- B. Preload
- C. Afterload
- D. Contractility
Correct Answer: D
Rationale: CO is dependent on the heart rate and stroke volume, and stroke volume is determined by preload, afterload and contractility. If CO is decreased and heart rate is unchanged, stroke volume is the variable factor.
What term refers to the degree of myocardial fiber stretch before contraction, related to the volume of blood distending the ventricles at the end of diastole, and determined by the amount of venous return?
- A. Preload
- B. Afterload
- C. Contractility
- D. Ejection fraction
Correct Answer: A
Rationale: Rationale:
1. Preload refers to myocardial fiber stretch before contraction.
2. It is related to the volume of blood in ventricles at end of diastole.
3. Preload is determined by the amount of venous return to the heart.
4. It influences the force of contraction and stroke volume.
5. Afterload (B) is the resistance the heart must overcome to pump blood.
6. Contractility (C) is the intrinsic strength of the heart muscle.
7. Ejection fraction (D) is the percentage of blood ejected from ventricles.
Summary:
- Preload is correct as it specifically relates to fiber stretch and volume of blood.
- Afterload, contractility, and ejection fraction do not directly relate to ventricular volume and venous return.
Identify the three layers of the heart:
- A. Endocardium, Myocardium, Epicardium
- B. Epicardium, Pericardium, Endocardium
- C. Myocardium, Endocardium, Pericardium
- D. Pericardium, Myocardium, Endocardium
Correct Answer: A
Rationale: Rationale:
1. Endocardium: Innermost layer lining the heart chambers.
2. Myocardium: Middle layer composed of cardiac muscle tissue.
3. Epicardium: Outermost layer forming the visceral pericardium.
Therefore, the correct answer is A.
Summary:
B is incorrect as it includes Pericardium instead of Myocardium.
C is incorrect as it switches the positions of Myocardium and Epicardium.
D is incorrect as it has the layers listed in the wrong order and includes Pericardium as the innermost layer.