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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.
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The nurse is caring for a client on amiodarone who develops a cough. What is the most appropriate action?
- A. Notify the healthcare provider immediately.
- B. Reassure the client that this is a common side effect.
- C. Continue the amiodarone and monitor the client's symptoms.
- D. Discontinue the amiodarone immediately.
Correct Answer: A
Rationale: Rationale for Correct Answer A: The nurse should notify the healthcare provider immediately because a cough can be a sign of a serious side effect of amiodarone called pulmonary toxicity. Prompt action is necessary to prevent further complications. The healthcare provider needs to assess the client, possibly order diagnostic tests, and determine the appropriate course of action.
Summary of Incorrect Choices:
B: Reassuring the client without further assessment could lead to delayed recognition of a serious issue.
C: Continuing amiodarone without addressing the cough may worsen the condition.
D: Discontinuing amiodarone without consulting the healthcare provider may not be appropriate and could lead to adverse effects or worsening of the client's condition.
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.
When reviewing a patient's four-week diet history, the cardiac-vascular nurse identifies a pattern of high-calorie intake on Monday, Wednesday, and Friday nights. The patient states that their spouse recently started taking a night class on those evenings at a local university. The patient's diet history indicates:
- A. a disabling family coping behavior.
- B. a lack of dietary instruction.
- C. a need for cooking classes.
- D. an individual coping behavior.
Correct Answer: D
Rationale: The eating pattern appears to be an individual coping behavior related to the spouse's absence.
What procedure uses a balloon to open narrowed or blocked blood vessels in the heart?
- A. Angioplasty
- B. Coronary artery bypass graft
- C. Stent placement
- D. Valve replacement
Correct Answer: A
Rationale: The correct answer is A: Angioplasty. This procedure uses a balloon to open narrowed or blocked blood vessels in the heart. First, a catheter with a deflated balloon is inserted into the blocked artery. Then, the balloon is inflated to widen the artery and improve blood flow. This is a minimally invasive procedure commonly used to treat coronary artery disease.
Choice B: Coronary artery bypass graft involves using blood vessels from another part of the body to bypass blocked arteries, not using a balloon.
Choice C: Stent placement involves inserting a mesh tube to keep the artery open, but it does not use a balloon to open the vessel.
Choice D: Valve replacement is a procedure to replace damaged heart valves and does not involve using a balloon to open narrowed arteries.
What is the procedure where a small mesh tube is inserted into an artery to keep it open after angioplasty?
- A. Stent placement
- B. Bypass surgery
- C. Angioplasty
- D. Valve replacement
Correct Answer: A
Rationale: The correct answer is A: Stent placement. After angioplasty, a stent is inserted into the artery to prevent it from collapsing and keep it open. This procedure helps maintain blood flow and reduces the risk of blockages. Bypass surgery involves redirecting blood flow using a graft, not inserting a tube. Angioplasty is the initial procedure to open the blocked artery, not to keep it open. Valve replacement is a procedure for replacing damaged heart valves, not for arteries.