Nokea
The nurse in the emergency department (ED) is caring for a client with a myocardial infarction. The nurse anticipates a prescription for which medications? Select all that apply.
- A. labetalol
- B. morphine sulfate
- C. nitroglycerin
- D. enalapril
- E. isosorbide
- F. diltiazem
Correct Answer: B,C,E
Rationale: Morphine sulfate (for pain), nitroglycerin (for vasodilation), and isosorbide (for preload reduction) are used in myocardial infarction. Labetalol, enalapril, and diltiazem are not first-line treatments.
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The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is caring for a client with septic shock
Item 1 of 1
Nurses' Notes
1400: Follow-up assessment after the infusion of 30 mL/kg of 0.9% saline bolus (1850 mL total) was infused. Vital signs: T 103.4° F (39.7° C), P 104, RR 22, BP 90/61, pulse oximetry reading 95% on room air.
1410: The physician was notified of the vital signs, and a verbal order for a dopamine drip was received for 5 mcg/kg/minute to titrate to a MAP of 65 mm Hg. The order was read back and verified.
1415: Dopamine infusion started in the client's right antecubital peripheral vascular access device.
1445: The client reports 'stinging' pain at the vascular access site. The site had erythema, swelling, and tenderness when touched. The infusion was stopped.
The nurse reviewed all nursing note entries and notified the physician of the vascular access device assessment findings. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress
- A. Obtain a prescription for phentolamine, Flush the vascular access device, Aspirate any residual medication, Restart the infusion at a lower rate.
- B. Extravasation, Hematoma, Infiltration, Phlebitis.
- C. Urinary output, Neurovascular status of affected extremity, Drainage at vascular access site, Pain level.
Correct Answer: B, A, C
Rationale: The client is experiencing extravasation (B) due to dopamine causing stinging, erythema, and swelling. Actions include obtaining phentolamine (A, an antidote for vasopressor extravasation) and aspirating residual medication (A). Monitor neurovascular status (C) and pain level (C) to assess progress.
The nurse is caring for a client with infective endocarditis. The nurse anticipates a prescription for which medication?
- A. Nitroglycerin
- B. Vancomycin
- C. Atorvastatin
- D. Aspirin
Correct Answer: B
Rationale: Vancomycin, an antibiotic, is used to treat infective endocarditis caused by bacterial infection. Nitroglycerin, atorvastatin, and aspirin are not indicated for this condition.
The nurse is caring for a client who is receiving prescribed cilostazol. Which of the following client findings would indicate a therapeutic response?
- A. Absence of pain while ambulating
- B. Decreased total cholesterol
- C. Increased visual acuity
- D. Improved focus and attention
Correct Answer: A
Rationale: Cilostazol is used to treat intermittent claudication, so the absence of pain while ambulating indicates a therapeutic response. It does not directly affect cholesterol, visual acuity, or focus.
A nurse is caring for a client who has developed bradycardia. Which prescription should the nurse question?
- A. Propranolol
- B. Furosemide
- C. Spironolactone
- D. Valsartan
Correct Answer: A
Rationale: Propranolol, a beta-blocker, can worsen bradycardia and should be questioned. Furosemide, spironolactone, and valsartan are less likely to affect heart rate.
The nurse is teaching a client about newly prescribed nitroglycerin (NTG) sublingual tablets. Which statement, if made by the client, would indicate a correct understanding of the teaching?
- A. I should allow this tablet to dissolve in my cheek.
- B. I should keep the tablets in the dark bottle.
- C. I should take this medication standing up to prevent indigestion.
- D. I should take one tablet every 7 to 10 minutes if I get chest pain.
Correct Answer: B
Rationale: Nitroglycerin sublingual tablets should be kept in a dark bottle to protect from light degradation, indicating correct understanding. They dissolve under the tongue, not in the cheek, are taken every 5 minutes for chest pain (up to 3 doses), and standing is not required.