Nokea
The client is receiving intravenous dopamine. What is the most important nursing assessment?
- A. Monitor heart rate and rhythm
- B. Monitor blood pressure
- C. Monitor respiratory rate
- D. Monitor oxygen saturation
Correct Answer: A
Rationale: The correct answer is A: Monitor heart rate and rhythm. Dopamine is a medication that can affect the heart rate and rhythm. Monitoring these parameters is crucial to detect any potential adverse effects such as tachycardia or arrhythmias. Monitoring blood pressure is also important, but assessing heart rate and rhythm takes precedence due to the direct impact of dopamine on cardiac function. Respiratory rate and oxygen saturation are generally not directly affected by dopamine administration.
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What test measures the pressure in the arteries during the contraction and relaxation of the heart?
- A. Blood pressure test
- B. Electrocardiogram (ECG or EKG)
- C. Spirometry
- D. Pulse oximetry
Correct Answer: A
Rationale: The correct answer is A: Blood pressure test. This test measures the pressure in the arteries during the heart's contraction (systolic pressure) and relaxation (diastolic pressure). It provides important information about heart health and overall cardiovascular function. The other choices are incorrect because B (ECG) measures the heart's electrical activity, C (Spirometry) measures lung function, and D (Pulse oximetry) measures oxygen saturation in the blood, not arterial pressure.
Pneumothorax symptoms.
- A. Chest pain
- B. Shortness of breath
- C. Both A and B
- D. None of the above
Correct Answer: C
Rationale: Symptoms include sharp chest pain and difficulty breathing.
What is a condition where the alveoli are gradually destroyed, leading to shortness of breath and reduced oxygen exchange?
- A. Emphysema
- B. Pulmonary fibrosis
- C. Pulmonary edema
- D. Lung cancer
Correct Answer: A
Rationale: Emphysema is the correct answer. Alveoli destruction in emphysema leads to shortness of breath and reduced oxygen exchange. This condition is primarily caused by smoking and results in irreversible damage to the air sacs in the lungs. Pulmonary fibrosis involves scarring of lung tissue, not alveoli destruction. Pulmonary edema is fluid accumulation in the lungs, disrupting oxygen exchange. Lung cancer is the uncontrolled growth of abnormal cells in the lung, which may not directly lead to alveoli destruction.
What structure separates the left and right sides of the heart?
- A. Interventricular septum
- B. Endocardium
- C. Epicardium
- D. Pericardium
Correct Answer: A
Rationale: The correct answer is A: Interventricular septum. This structure separates the left and right sides of the heart, forming a barrier between the two ventricles. It ensures that oxygenated and deoxygenated blood do not mix within the heart chambers. The endocardium (B) is the inner layer of the heart's chambers, the epicardium (C) is the outer layer of the heart, and the pericardium (D) is the sac surrounding the heart. These structures do not specifically separate the left and right sides of the heart.
The client is on spironolactone (Aldactone) and has a potassium level of 5.9 mEq/L. What is the nurse's priority action?
- A. Hold the spironolactone and notify the healthcare provider.
- B. Administer potassium supplements.
- C. Continue the spironolactone as ordered.
- D. Increase the dose of spironolactone.
Correct Answer: A
Rationale: The correct answer is A: Hold the spironolactone and notify the healthcare provider. Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. With a potassium level of 5.9 mEq/L, the client is at risk for serious complications like cardiac arrhythmias. The priority action is to stop the medication to prevent further elevation of potassium levels and inform the healthcare provider for further management. Administering potassium supplements (B) would worsen the hyperkalemia. Continuing spironolactone (C) or increasing the dose (D) would be inappropriate and potentially harmful in this situation.