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The client on a beta blocker has a blood pressure of 88/58 mm Hg. What is the nurse's priority action?
- A. Hold the beta blocker and notify the healthcare provider.
- B. Administer the beta blocker as ordered.
- C. Increase the dose of the beta blocker.
- D. Continue to monitor the client and reassess in 30 minutes.
Correct Answer: A
Rationale: The correct answer is A: Hold the beta blocker and notify the healthcare provider. A blood pressure of 88/58 mm Hg is considered hypotension, which can be a serious side effect of beta blockers. By holding the medication and notifying the healthcare provider, the nurse ensures prompt assessment and appropriate intervention. Administering the beta blocker (B) could further lower the blood pressure. Increasing the dose (C) would exacerbate the hypotension. Continuing to monitor and reassess (D) is not sufficient as immediate action is required due to the low blood pressure reading.
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The client on spironolactone (Aldactone) has a potassium level of 5.8 mEq/L. What is the nurse's priority action?
- A. Hold the spironolactone and notify the healthcare provider.
- B. Administer a potassium supplement.
- 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. The priority action is to stop the medication and inform the healthcare provider because a potassium level of 5.8 mEq/L is above the normal range (3.5-5.0 mEq/L), indicating hyperkalemia. Spironolactone is a potassium-sparing diuretic that can further increase potassium levels. Continuing the medication or administering a potassium supplement would exacerbate the issue. Increasing the dose of spironolactone would be unsafe and could lead to severe complications. Therefore, holding the medication and seeking guidance from the healthcare provider is crucial in managing the client's elevated potassium level.
You are working with an experienced nursing assistant and LPN/LVN in caring for a group of patients. You have developed a nursing diagnosis of Activity Intolerance related to fatigue and chest pain for a patient who had an acute myocardial infarction 3 days ago. Which of these nursing activities included in the care plan is best delegated to the LPN/LVN?
- A. Administer nitroglycerin (Nitro-Stat) if chest discomfort occurs during patient activities.
- B. Monitor pulse, blood pressure, and oxygen saturation before and after patient ambulation.
- C. Teach the patient energy conservation techniques to decrease myocardial oxygen demand.
- D. Explain the rationale for alternating rest periods with exercise to the patient and family.
Correct Answer: B
Rationale: Monitoring vital signs is within the scope of practice for an LPN/LVN and does not require advanced assessment skills.
What is a condition characterized by an abnormal buildup of fluid between the layers of tissue lining the lungs and chest cavity?
- A. Pleural effusion
- B. Pulmonary edema
- C. Atelectasis
- D. Sarcoidosis
Correct Answer: A
Rationale: Pleural effusion is the correct answer because it specifically describes the abnormal buildup of fluid between the layers of tissue lining the lungs and chest cavity. This condition can cause symptoms like chest pain and difficulty breathing. Pulmonary edema, on the other hand, is the accumulation of fluid in the lung's air sacs, leading to breathing difficulties. Atelectasis refers to the collapse of a lung or a portion of it, not fluid buildup. Sarcoidosis is a disease that causes inflammation in various organs, not specifically fluid accumulation in the lungs. Therefore, pleural effusion best matches the described condition.
If Mr. Lane, with essential hypertension, complains of dizziness when changing position, your evaluation would be that Mr. Lane
- A. is probably not taking his medications properly
- B. should be instructed in preventing hypotensive reactions
- C. is responding as expected to the prescribed medications
- D. should be totally reevaluated
Correct Answer: B
Rationale: Dizziness may indicate postural hypotension, requiring preventive education.
Which of the following is a chronic lung disease that includes conditions such as chronic bronchitis and emphysema, characterized by obstructed airflow from the lungs?
- A. Chronic obstructive pulmonary disease (COPD)
- B. Pulmonary fibrosis
- C. Asthma
- D. Pneumonia
Correct Answer: A
Rationale: The correct answer is A: Chronic obstructive pulmonary disease (COPD). COPD is characterized by chronic bronchitis and emphysema, leading to obstructed airflow from the lungs. Chronic bronchitis involves inflammation of the bronchial tubes, while emphysema damages the air sacs in the lungs. Pulmonary fibrosis (B) is scarring of lung tissue, not obstructed airflow. Asthma (C) is a condition where airways narrow and swell, not necessarily leading to obstructed airflow. Pneumonia (D) is an infection in the lungs, not a chronic disease causing obstructed airflow.