Nokea
The client on furosemide (Lasix) has a potassium level of 3.1 mEq/L. What is the nurse's priority action?
- A. Administer a potassium supplement.
- B. Hold the furosemide and notify the healthcare provider.
- C. Continue the current dose of furosemide.
- D. Administer Digibind.
Correct Answer: A
Rationale: The correct answer is A because a potassium level of 3.1 mEq/L indicates hypokalemia, a common side effect of furosemide. Administering a potassium supplement is essential to prevent complications like cardiac dysrhythmias. Choice B is incorrect because holding furosemide can worsen the client's condition. Choice C is incorrect as continuing the current dose can further lower potassium levels. Choice D is incorrect as Digibind is used to treat digoxin toxicity, not hypokalemia. Administering a potassium supplement addresses the underlying issue.
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Which measure is used to relieve the symptoms of left-sided heart failure?
- A. Weighing the patient daily
- B. Applying an abdominal binder
- C. Maintaining total bed rest
- D. Elevating the patient's head
Correct Answer: D
Rationale: Head elevation reduces pulmonary congestion.
As the charge nurse in a long-term-care (LTC) facility that has RN, LPN/LVN, and nursing assistant staff members, you have developed a plan for ongoing assessment of all residents with a diagnosis of heart failure. Which of these activities included in the plan is most appropriate to delegate to an LPN/LVN team leader?
- A. Weigh all residents with heart failure each morning.
- B. Listen to lung sounds and check for edema weekly.
- C. Review all heart failure medications with residents every month.
- D. Update activity plans for residents with heart failure every quarter.
Correct Answer: A
Rationale: Weighing residents is a routine task suitable for delegation to an LPN/LVN.
Priority Decision: While teaching women about the risks and incidence of CAD, what does the nurse emphasize?
- A. Smoking is not as significant a risk factor for CAD in women as it is in men
- B. Women seek treatment sooner than men when they have symptoms of CAD
- C. Estrogen replacement therapy in postmenopausal women decreases the risk for CAD
- D. CAD is the leading cause of death in women, with a higher mortality rate after MI than in men
Correct Answer: D
Rationale: CAD is a major cause of mortality in women.
What is a surgical procedure to replace a damaged or diseased heart valve with a prosthetic valve?
- A. Valve replacement
- B. Angioplasty
- C. Stent placement
- D. Bypass surgery
Correct Answer: A
Rationale: The correct answer is A: Valve replacement. This surgical procedure involves replacing a damaged or diseased heart valve with a prosthetic valve to restore proper heart function. It is specifically targeted at addressing heart valve issues, making it the most appropriate choice. Angioplasty (B) is a procedure to open blocked arteries, not related to heart valve replacement. Stent placement (C) involves inserting a mesh tube to keep arteries open, not addressing heart valve issues. Bypass surgery (D) is performed to improve blood flow to the heart muscle, not focused on replacing heart valves. Thus, A is the correct choice for the given question.
The client on nitroglycerin complains of a headache. What is the most appropriate response by the nurse?
- A. Administer acetaminophen as prescribed for the headache.
- B. Hold the next dose of nitroglycerin.
- C. Discontinue the nitroglycerin immediately.
- D. Notify the healthcare provider immediately.
Correct Answer: A
Rationale: The correct response is to administer acetaminophen as prescribed for the headache. This is because headaches are a common side effect of nitroglycerin due to vasodilation. Acetaminophen can help relieve the headache without interfering with the therapeutic effects of nitroglycerin. Holding the next dose (B) is not appropriate as it can lead to inadequate treatment of the client's condition. Discontinuing nitroglycerin (C) abruptly can be dangerous as it may cause rebound hypertension. Notifying the healthcare provider (D) is not necessary unless the headache persists or worsens.