Nokea
The client with a history of angina pectoris reports chest pain unrelieved by nitroglycerin. Which action should the nurse take next?
- A. Administer another dose of nitroglycerin.
- B. Notify the healthcare provider immediately.
- C. Have the client lie down and rest.
- D. Encourage the client to take deep breaths.
Correct Answer: B
Rationale: When a client with a history of angina pectoris reports chest pain unrelieved by nitroglycerin, it may indicate a myocardial infarction, also known as a heart attack. In this situation, the nurse should immediately notify the healthcare provider to ensure prompt evaluation and appropriate intervention. Delay in seeking medical attention for chest pain unrelieved by nitroglycerin can be life-threatening, as it might be a sign of a more serious cardiac event. Administering another dose of nitroglycerin (Choice A) without further evaluation can be risky, as the client's condition may require a different intervention. Having the client lie down and rest (Choice C) or encouraging deep breaths (Choice D) are not appropriate actions in this scenario where a more serious cardiac event needs to be ruled out.
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The nurse is caring for a client with hypertension who is prescribed a thiazide diuretic. The nurse should check which parameter before administering the medication?
- A. Serum potassium level
- B. Blood pressure
- C. Heart rate
- D. Serum sodium level
Correct Answer: B
Rationale: Before administering a thiazide diuretic to a client with hypertension, the nurse should check the blood pressure. Thiazide diuretics are prescribed to lower blood pressure, so assessing the client's blood pressure prior to administration helps to monitor the effectiveness of the medication and to ensure the client's safety. Checking the serum potassium level (Choice A), heart rate (Choice C), or serum sodium level (Choice D) are also important parameters in the care of a client on a thiazide diuretic, but the priority assessment before administering the medication is the blood pressure to evaluate the drug's effectiveness in managing hypertension.
The client is receiving furosemide (Lasix) for heart failure. What potential side effect should the nurse monitor for?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hypernatremia
- D. Hypoglycemia
Correct Answer: A
Rationale: The correct answer is A: Hypokalemia. Furosemide, a loop diuretic, causes potassium loss, leading to hypokalemia. Monitoring potassium levels is crucial because hypokalemia can result in cardiac arrhythmias and muscle weakness. Choices B, C, and D are incorrect because furosemide does not typically cause hyperkalemia, hypernatremia, or hypoglycemia.
The nurse is assisting with the care of a client who is on a continuous heparin infusion for deep vein thrombosis (DVT). Which laboratory test should the nurse monitor to evaluate the effectiveness of the therapy?
- A. Prothrombin time (PT)
- B. Activated partial thromboplastin time (aPTT)
- C. International normalized ratio (INR)
- D. Platelet count
Correct Answer: B
Rationale: To evaluate the effectiveness of heparin therapy in a client with DVT, the nurse should monitor the activated partial thromboplastin time (aPTT). The aPTT test helps ensure that the dose of heparin is within the therapeutic range, which is essential for preventing clot formation or excessive bleeding. Monitoring aPTT is crucial in managing patients on heparin therapy to maintain the delicate balance between preventing thrombosis and avoiding hemorrhage. Prothrombin time (PT) and International normalized ratio (INR) are more indicative of warfarin therapy effectiveness, not heparin. Platelet count assesses platelet levels and function, not the effectiveness of heparin therapy for DVT.
A client is taking furosemide. Which of the following findings should the nurse report to the provider?
- A. Weight gain
- B. Dry cough
- C. Hypokalemia
- D. Increased appetite
Correct Answer: C
Rationale: Furosemide is a loop diuretic that can lead to potassium loss, resulting in hypokalemia. Hypokalemia is a serious electrolyte imbalance that can cause various cardiac and muscular issues. Therefore, the nurse should promptly report hypokalemia to the healthcare provider for appropriate management. Choices A, B, and D are incorrect because weight gain, dry cough, and increased appetite are not typically associated with furosemide use and are not immediate concerns that require urgent reporting.
Before administering a calcium channel blocker to a client with hypertension, what parameter should the nurse check?
- A. Serum calcium level
- B. Apical pulse
- C. Blood pressure
- D. Respiratory rate
Correct Answer: C
Rationale: Before administering a calcium channel blocker to a client with hypertension, the nurse should check the client's blood pressure. Calcium channel blockers are prescribed to lower blood pressure, so it is essential to assess the current blood pressure to ensure safe administration and monitor the medication's effectiveness. Checking the serum calcium level (Choice A) is not necessary before administering a calcium channel blocker, as it does not directly impact the drug's action. Monitoring the apical pulse (Choice B) is important for other types of medications like beta-blockers, not specifically for calcium channel blockers. Assessing the respiratory rate (Choice D) is not directly related to administering calcium channel blockers for hypertension.