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The healthcare professional is caring for a client who has just returned from a cardiac catheterization. The healthcare professional should prioritize which assessment?
- A. Monitoring the client's vital signs every 4 hours
- B. Assessing the puncture site for bleeding
- C. Encouraging the client to ambulate early to prevent complications
- D. Providing the client with fluids to flush out the contrast dye
Correct Answer: B
Rationale: Assessing the puncture site for bleeding is a critical assessment after a cardiac catheterization procedure. This is essential to detect and address any potential complications promptly, such as hemorrhage or hematoma formation. Monitoring the puncture site helps ensure early intervention and prevent further complications, making it the priority assessment in this situation.
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After a client with a history of myocardial infarction (MI) is prescribed aspirin, which instruction should the nurse include in the discharge teaching?
- A. Take the aspirin with food to prevent gastrointestinal upset
- B. Discontinue the aspirin if you experience ringing in your ears
- C. Take the aspirin at bedtime to minimize side effects
- D. Avoid taking aspirin if you are also taking other NSAIDs
Correct Answer: A
Rationale: The correct instruction is to take aspirin with food to prevent gastrointestinal upset. Aspirin can irritate the stomach lining, leading to potential gastrointestinal issues. Taking it with food helps reduce this risk by providing a protective layer in the stomach. This is a common recommendation to minimize the risk of gastrointestinal side effects when taking aspirin.
A client with a history of heart failure is admitted with a diagnosis of pulmonary edema. Which intervention should the LPN/LVN expect to assist with first?
- A. Administer a diuretic as prescribed.
- B. Place the client in a high Fowler's position.
- C. Prepare the client for intubation.
- D. Insert an indwelling urinary catheter.
Correct Answer: B
Rationale: In a client with pulmonary edema, placing them in a high Fowler's position is the priority intervention. This position helps to improve ventilation and oxygenation by decreasing venous return, reducing the workload on the heart, and facilitating fluid redistribution from the lungs. It is crucial to optimize respiratory function and oxygenation before considering other interventions like administering medications, preparing for intubation, or inserting a urinary catheter.
A client with heart failure is prescribed furosemide (Lasix). The nurse should monitor the client for which potential electrolyte imbalance?
- A. Hyperkalemia
- B. Hypernatremia
- C. Hypokalemia
- D. Hypocalcemia
Correct Answer: C
Rationale: When a client with heart failure is prescribed furosemide, the nurse should monitor for hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss, which increases the risk of hypokalemia. Hypokalemia can have serious implications such as cardiac dysrhythmias. Therefore, it is essential to closely monitor the client's serum potassium levels while on furosemide to prevent complications.
The LPN/LVN is assisting in the care of a client with chronic heart failure who is receiving furosemide (Lasix). Which instruction should the nurse reinforce with the client?
- A. Limit your fluid intake to avoid fluid overload.
- B. Increase your potassium intake by eating bananas and oranges.
- C. Weigh yourself once a week to monitor for fluid retention.
- D. Take the medication at night to avoid frequent urination during the day.
Correct Answer: B
Rationale: The correct instruction for the nurse to reinforce with the client is to increase potassium intake by eating bananas and oranges. Furosemide can lead to potassium loss, potentially causing hypokalemia. By increasing potassium intake through diet, the client can help prevent this electrolyte imbalance and maintain overall health.
The client is receiving enalapril (Vasotec). The nurse should monitor the client for which potential adverse effect?
- A. Hypertension
- B. Hypotension
- C. Tachycardia
- D. Hyperglycemia
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.