Nokea
The client on enoxaparin (Lovenox) is scheduled for surgery. What is the nurse's priority action?
- A. Hold the enoxaparin and notify the healthcare provider.
- B. Administer the enoxaparin as scheduled.
- C. Administer vitamin K before the surgery.
- D. Monitor the client's INR and proceed with surgery.
Correct Answer: A
Rationale: The correct answer is A: Hold the enoxaparin and notify the healthcare provider. Enoxaparin is an anticoagulant that increases the risk of bleeding during surgery. Holding it reduces this risk. Notifying the healthcare provider is crucial for further guidance. Administering enoxaparin (B) can lead to excessive bleeding. Administering vitamin K (C) is not indicated for enoxaparin therapy. Monitoring INR (D) is not appropriate for enoxaparin, which does not affect INR levels.
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What is a chronic condition where the heart is unable to pump blood efficiently, leading to fluid buildup in the lungs and other parts of the body?
- A. Heart failure
- B. Cardiomyopathy
- C. Pericarditis
- D. Aortic stenosis
Correct Answer: A
Rationale: Step 1: Heart failure is a chronic condition where the heart is unable to pump blood efficiently.
Step 2: This inefficiency leads to fluid buildup in the lungs (pulmonary congestion) and other parts of the body.
Step 3: Cardiomyopathy is a broad term for diseases that affect the heart muscle but may not necessarily result in heart failure.
Step 4: Pericarditis is inflammation of the pericardium, the sac surrounding the heart, not directly related to heart pumping efficiency.
Step 5: Aortic stenosis is a condition where the aortic valve narrows, affecting blood flow from the heart but not necessarily leading to heart failure.
Which of the following is a chronic condition where the heart muscle is weakened and unable to pump blood effectively, often leading to heart failure?
- A. Dilated cardiomyopathy
- B. Hypertrophic cardiomyopathy
- C. Restrictive cardiomyopathy
- D. Myocarditis
Correct Answer: A
Rationale: Rationale:
1. Dilated cardiomyopathy (A) is characterized by the heart muscle becoming weak and enlarged, leading to ineffective pumping.
2. Hypertrophic cardiomyopathy (B) involves thickened heart muscle but not necessarily weakened.
3. Restrictive cardiomyopathy (C) involves stiffening of the heart muscle, not necessarily weakening.
4. Myocarditis (D) is inflammation of the heart muscle, not specifically related to chronic weakening and heart failure.
Therefore, A is the correct answer as it directly relates to the weakened heart muscle leading to ineffective pumping and heart failure.
Which of the following is a rare genetic disorder that affects the lungs, liver, and skin, causing the buildup of a specific protein that damages organs?
- A. Alpha-1 antitrypsin deficiency
- B. Cystic fibrosis
- C. Wegener's granulomatosis
- D. Marfan syndrome
Correct Answer: A
Rationale: Alpha-1 antitrypsin deficiency is the correct answer. This disorder affects the lungs, liver, and skin due to the buildup of a specific protein (alpha-1 antitrypsin) that damages organs. This deficiency can lead to lung and liver diseases. Cystic fibrosis primarily affects the lungs and digestive system, not the liver and skin. Wegener's granulomatosis is a condition that affects the blood vessels, lungs, and kidneys, not the liver. Marfan syndrome is a connective tissue disorder that affects the heart, blood vessels, bones, and eyes, not the lungs, liver, and skin.
A patient with cardiogenic shock receives a nursing diagnosis of decreased cardiac output. With the appropriate interventions, the anticipated outcome is for the patient to achieve:
- A. baseline activity level.
- B. baseline cardiac function.
- C. decreased afterload.
- D. reduced anxiety.
Correct Answer: B
Rationale: Restoring baseline cardiac function is the goal in managing decreased cardiac output.
The healthcare provider is monitoring a client on an ACE inhibitor. What lab value is most important to monitor?
- A. Potassium
- B. Sodium
- C. Creatinine
- D. Calcium
Correct Answer: A
Rationale: The correct answer is A: Potassium. ACE inhibitors can cause hyperkalemia, so monitoring potassium levels is crucial to prevent potential life-threatening complications. High potassium levels can lead to cardiac arrhythmias. Sodium levels are not typically affected by ACE inhibitors. Creatinine is important to monitor for kidney function but not specific to ACE inhibitors. Calcium levels are not directly affected by ACE inhibitors.