Nokea
The client on furosemide is at risk for which electrolyte imbalance?
- A. Hypokalemia
- B. Hypernatremia
- C. Hyperkalemia
- D. Hyponatremia
Correct Answer: A
Rationale: The correct answer is A: Hypokalemia. Furosemide is a loop diuretic that increases potassium excretion in the urine, leading to low potassium levels (hypokalemia). This can cause muscle weakness, cramps, and cardiac arrhythmias. Hypernatremia (B) is high sodium levels, unrelated to furosemide. Hyperkalemia (C) is the opposite of what furosemide causes. Hyponatremia (D) is low sodium levels, not typically associated with furosemide use.
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The nurse is giving a client an IV bolus of heparin. What is the most important nursing action?
- A. Monitor the client's heart rate.
- B. Check the client's blood pressure.
- C. Check for signs of bleeding.
- D. Monitor the client's respiratory rate.
Correct Answer: A
Rationale: The correct answer is A: Monitor the client's heart rate. When administering an IV bolus of heparin, it is crucial to monitor the client's heart rate because heparin can cause serious side effects such as bleeding and heparin-induced thrombocytopenia, which can lead to changes in heart rate. Checking blood pressure (B) is also important but not as critical as monitoring heart rate. Checking for signs of bleeding (C) is necessary but should be done after monitoring the heart rate. Monitoring the client's respiratory rate (D) is not directly related to heparin administration.
What is a procedure to remove fluid or air from the pleural space to help a patient breathe easier?
- A. Thoracentesis
- B. Bronchoscopy
- C. Chest X-ray
- D. CT scan
Correct Answer: A
Rationale: Thoracentesis is the correct answer because it is a procedure used to remove fluid or air from the pleural space, which can help a patient breathe easier. The steps involved in thoracentesis include identifying the location for insertion, numbing the area with local anesthesia, inserting a needle or catheter into the pleural space, draining the fluid or air, and monitoring the patient for any complications.
Summary:
- B: Bronchoscopy is a procedure used to visualize the airways and diagnose lung conditions, not to remove fluid or air from the pleural space.
- C: Chest X-ray is an imaging test used to visualize the chest area and diagnose various conditions, but it does not involve removing fluid or air from the pleural space.
- D: CT scan is an imaging test that provides detailed images of the internal structures of the body, but it is not a procedure for removing fluid or air from the pleural space.
This heart condition is characterized by decreased cardiac output and tissue perfusion, which can lead to organ failure.
- A. Cardiogenic shock
- B. Myocardial infarction
- C. Endocarditis
- D. Pericarditis
Correct Answer: A
Rationale: The correct answer is A: Cardiogenic shock. Cardiogenic shock is characterized by decreased cardiac output and tissue perfusion due to the heart's inability to pump effectively, leading to organ failure. This condition is a result of heart failure or myocardial infarction. Myocardial infarction (choice B) is a cause of cardiogenic shock, but not the specific condition described. Endocarditis (choice C) and pericarditis (choice D) do not directly result in decreased cardiac output and tissue perfusion leading to organ failure like cardiogenic shock does.
The nurse is administering an ACE inhibitor to a client. What is the most common side effect?
- A. Cough
- B. Dizziness
- C. Hypotension
- D. Hyperkalemia
Correct Answer: A
Rationale: The correct answer is A: Cough. ACE inhibitors commonly cause a persistent dry cough due to the accumulation of bradykinin. This side effect occurs in up to 20% of patients. Dizziness (B) and hypotension (C) are potential side effects of ACE inhibitors but not as common as cough. Hyperkalemia (D) can occur with ACE inhibitors but is not the most common side effect.
In Mrs. Jones' discharge teaching with a permanent pacemaker, which point should be covered?
- A. She should not get pregnant because her heart would not be able to tolerate the increased workload
- B. She should not exercise regularly
- C. She can return to the degree of sexual activity that is desired and tolerable for her
- D. It is not necessary to make a return visit to her physician
Correct Answer: C
Rationale: Sexual activity can generally continue with appropriate precautions.