Nokea
The nurse has reviewed the information from the Prescriptions. The nurse is reinforcing education on heart failure management. Which of the following client statements indicate a correct understanding of the teaching? Select all that apply.
- A. I am going to join a cardiac rehabilitation program
- B. I should take my furosemide at bedtime."
- C. I will check my blood pressure before each dose of carvedilol.
- D. I will notify my health care provider if I develop muscle cramps.
- E. I will weigh myself once a week.
Correct Answer: A,C,D
Rationale: Pharmacological management of heart failure (HF) focuses on reducing cardiac workload and improving cardiac output. Beta
blockers (eg, carvedilol) reduce cardiac workload by inhibiting the action of catecholamines (eg, epinephrine, norepinephrine)
on beta-adrenergic receptors in the heart. Beta blockers decrease myocardial oxygen demand by decreasing blood
pressure (BP) and heart rate (HR). Therefore, clients prescribed antihypertensive medications (eg, carvedilol) should be
instructed to check BP and HR before each dose to monitor for hypotension and bradycardia
Loop diuretics (eg, furosemide, bumetanide) are potassium-wasting, which increases the client's risk of hypokalemia
Angiotensin system inhibitors (eg, sacubitril-valsartan) and potassium supplements cause hyperkalemia. Clients should be
taught symptoms of hypo- or hyperkalemia (eg, muscle cramps) and instructed to notify the health care provider if they occur
(Option 4).
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Drag words from the choices below to fill in the blanks. The nurse gathers supplies for medication administration. The nurse recognizes that the priority prescriptions are -------and ----------
- A. 50% dextrose IV PRN
- B. 0.9% sodium chloride IV bolus
- C. Potassium chloride IV PRN|
- D. Regular insulin continuous IV infusion
- E. 5% dextrose in 0.45% sodium chloride IV infusion
Correct Answer: E,B
Rationale: The priority intervention for management of diabetic ketoacidosis is fluid resuscitation with isotonic IV fluid, typically starting with large-voli
0.9% sodium chloride IV boluses (eg, 1 L/hr) to prevent life-threatening hypovolemic shock. Fluid resuscitation also helps normalize
glucose and electrolyte levels via hemodilution. After initial large-volume boluses are complete, either hypotonic or isotonic IV fluids are
administered at continuous rate. Administration of regular insulin continuous IV infusion is also essential to correct hyperglycemia.
Which of the following findings indicate that the client is improving as expected? Select all that apply.
- A. Blood pressure 138/70 mm Hg
- B. Clear lung sounds
- C. Increased urinary output
- D. SpO, 95% on room air
- E. Unilateral lower extremity edema
Correct Answer: A,B,C,D
Rationale: Clinical improvement in a client with heart failure includes manifestations of reduced cardiac workload and improved fluid
volume status and gas exchange. A decrease in blood pressure from 170/100 mm Hg to 138/70 mm Hg and increased
urinary output indicate effectiveness of diuretics to reduce circulatory fluid volume and antihypertensive medications to
decrease cardiac workload . In addition, clear lung sounds and an increased capillary oxygen
saturation (SpO2) indicate a decrease in pulmonary congestion and an improvement in fluid volume status
Drag words from the choices below to fill in the blanks.The nurse recognizes that the client likely has hyperemesis gravidarum and should monitor for the following maternal complications:---------,------------------, AND -------------
- A. Fluid and electrolyte imbalances
- B. Insufficient gestational weight gain
- C. Intraamniotic infection (chorioamnionitis)
- D. Thyrotoxicosis
- E. Placental abruption
- F. Nutritional deficiencies
Correct Answer: A,B,F
Rationale: Without appropriate treatment, clients with hyperemesis gravidarum are at risk for multiple complications, including:
• Insufficient gestational weight gain, which may be associated with fetal/newborn complications such as preterm birth and a small-for-
gestational-age infant
• Fluid and electrolyte imbalances (eg, hypokalemia) resulting from excessive vomiting and decreased fluid and nutritional intake, whic
could cause life-threatening complications (eg, cardiac dyshythmias) if not corrected
• Nutritional deficiencies (eg, protein, vitamin) resulting from decreased oral intake, which may lead to rare but serious complications
(eg, Wernicke encephalopathy from thiamine [vitamin B1] deficiency)
The nurse has reviewed the information from the Nurses' Notes. Complete the following sentence/sentences by choosing from the list/lists of options. After removing the blankets from the client's room, the nurse should ----------------and ----------
- A. Initiate 1-to-1 observation
- B. Request a prescription for alprazolam
- C. Lock the door to the client's room during the day
- D. Notify the health care provider
- E. Document the client's behavior
- F. Restrict the client to the unit unless accompanied by a family member
Correct Answer: D,A
Rationale: After removing the blankets from the client's room, the nurse should notify the health are provider and initiate 1-to-1observation.This client is at high risk for imminent suicide. The client has severe depression, suicidal ideation with a plan, and access to lethal means (eg, blankets that can be used for self-hanging). This client requires constant visual ontact (ie, 1-to-1observation) to ensure safety 24 hours a day. The nurse should also notify the health care provider to assess for underlying psychiatric disorders (eg, psychosis) that could contribute to the situation.
The client is admitted to the inpatient mental health unit. For each potential intervention, click to specify if the intervention is appropriate or not appropriate for the care of the client.
- A. Assign the client to a shared room if available
- B. Avoid placing utensils on the client's meal tray
- C. Check on the client at frequent, irregular intervals
- D. Perform frequent room searches for harmful objects
- E. Perform mouth checks after medication administration
- F. Encourage the client to participate in grooming and hygiene
- G. Avoid discussion of suicidal thoughts when talking to the client
Correct Answer:
Rationale: Appropriate interventions for the client with major depressive disorder who is experiencing suicidal ideation include the
following:
• Assigning the client to a shared room near the nurses' station to reduce social isolation and allow easier access to the
client
• Avoiding utensils on the client's meal tray that could be used for self-harm
• Checking on the client at frequent, irregular intervals (if not under 1-to-1 observation) to lessen predictability of staff
surveillance
• Performing frequent room searches for harmful objects to ensure client safety
• Performing mouth checks after medication administration to ensure the client has swallowed medication and is not
saving them for a future overdose attempt
• Encouraging the client to participate in grooming and hygiene because the client may exhibit loss of interest in daily
activities, decreased energy, and lack of motivation
Avoiding discussion of suicidal thoughts is not appropriate. Clients with suicidal ideation are often reluctant to disclose
their thoughts unless asked directly. The nurse should establish a nonjudgmental, therapeutic relationship that allows for open
communication.
It is not appropriate for the nurse to document that the client is not available for a safety check when the client is using the
restroom. The nurse must ensure that there is visual contact with the client during safety checks, even if the client is in the
restroom, to ensure safety.