Nokea
The nurse is administering a beta blocker to a client with a heart rate of 58 bpm. What is the nurse's priority action?
- A. Administer the beta blocker as ordered.
- B. Hold the beta blocker and notify the healthcare provider.
- C. Increase the dose of the beta blocker.
- D. Monitor the client's heart rate and reassess in 30 minutes.
Correct Answer: B
Rationale: The correct answer is B. Holding the beta blocker and notifying the healthcare provider is the priority action because a heart rate of 58 bpm may be too low to safely administer a beta blocker, which can further decrease heart rate and lead to complications like bradycardia or heart block. Increasing the dose (choice C) without assessing the current heart rate is risky. Administering the beta blocker as ordered (choice A) without considering the low heart rate is unsafe. Monitoring the client's heart rate (choice D) is important but not the priority when the initial heart rate is low.
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The client on clopidogrel (Plavix) should be monitored for which adverse effect?
- A. Bleeding
- B. Hypertension
- C. Tachycardia
- D. Bradycardia
Correct Answer: A
Rationale: The correct answer is A: Bleeding. Clopidogrel is an antiplatelet medication that can increase the risk of bleeding due to its mechanism of action in preventing blood clot formation. Monitoring for signs of bleeding such as easy bruising, prolonged bleeding from cuts, blood in urine or stool is crucial.
Incorrect Choices:
B: Hypertension - Clopidogrel does not typically cause hypertension.
C: Tachycardia - Clopidogrel does not affect heart rate in a way that would lead to tachycardia.
D: Bradycardia - Clopidogrel is not associated with causing bradycardia.
In summary, monitoring for bleeding is essential when a client is on clopidogrel due to its antiplatelet effects, while hypertension, tachycardia, and bradycardia are not typically associated adverse effects of this medication.
For which of the following should Mr. Murphy contact his physician following bypass surgery?
- A. A generalized feeling of being weak and tired
- B. Incisional discomfort for 4 postoperative weeks
- C. The presence of some pink drainage from the leg incision site
- D. Inability to increase walking distance without pain
Correct Answer: D
Rationale: Difficulty increasing activity may indicate complications.
During a clinic appointment, a patient states, 'I came in because my calcium score was positive on my CT scan last week.' In which section of the patient assessment does the cardiac-vascular nurse document this finding?
- A. Past medical history.
- B. Personal/social history.
- C. Presenting problem.
- D. Review of symptoms.
Correct Answer: C
Rationale: The presenting problem section documents the reason for the current visit.
What accurately describes the pathophysiology of CAD?
- A. Partial or total occlusion of the coronary artery occurs during the stage of raised fibrous plaque
- B. Endothelial alteration may be caused by chemical irritants such as hyperlipidemia or by tobacco use
- C. Collateral circulation in the coronary circulation is more likely to be present in the young patient with CAD
- D. The leading theory of atherogenesis proposes that infection and fatty dietary intake are the basic underlying causes of atherosclerosis
Correct Answer: B
Rationale: Endothelial damage initiates plaque formation.
The client on spironolactone (Aldactone) has a potassium level of 5.6 mEq/L. What is the nurse's priority action?
- A. Hold the spironolactone and notify the healthcare provider.
- B. Administer potassium supplements.
- C. Continue the spironolactone as ordered.
- D. Increase the dose of spironolactone.
Correct Answer: A
Rationale: The correct answer is A: Hold the spironolactone and notify the healthcare provider. A potassium level of 5.6 mEq/L is elevated (normal range is 3.5-5.0 mEq/L). Spironolactone is a potassium-sparing diuretic, so the priority action is to hold the medication to prevent further elevation of potassium levels, which can lead to serious cardiac arrhythmias. Notifying the healthcare provider is crucial for further management. Administering potassium supplements (B) would further increase potassium levels. Continuing spironolactone as ordered (C) would exacerbate hyperkalemia. Increasing the dose of spironolactone (D) would be contraindicated in this situation.