Nokea
The nurse is administering morning medications to clients on a telemetry unit. Which medication would the nurse question?
- A. Furosemide IVP to a client with a potassium level of 3.6 mEq/L.
- B. Digoxin orally to a client diagnosed with rapid atrial fibrillation.
- C. Enalapril orally to a client whose BP is 86/64 and apical pulse is 65.
- D. Morphine IVP to a client complaining of chest pain and who is diaphoretic.
Correct Answer: C
Rationale: Enalapril (C) is contraindicated with hypotension (BP 86/64), risking further BP drop. Furosemide with K+ 3.6 (A), digoxin for AF (B), and morphine for chest pain (D) are appropriate.
You may also like to solve these questions
The client with coronary artery disease is prescribed transdermal nitroglycerin, a coronary vasodilator. Which behavior indicates the client understands the discharge teaching concerning this medication?
- A. The client places the medication under the tongue.
- B. The client removes the old patch before placing the new.
- C. The client applies the patch to a hairy area.
- D. The client changes the patch every 36 hours.
Correct Answer: B
Rationale: Removing the old patch (B) ensures proper dosing and prevents overdose. Sublingual (A) is incorrect, hairy areas (C) reduce adhesion, and patches are changed every 24 hours (D).
The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure?
- A. An elevated B-type natriuretic peptide (BNP).
- B. An elevated creatine kinase (CK-MB).
- C. A positive D-dimer.
- D. A positive ventilation/perfusion (V/Q) scan.
Correct Answer: A
Rationale: Elevated BNP (A) is specific to heart failure, reflecting ventricular stress. CK-MB (B) indicates myocardial infarction, D-dimer (C) suggests clotting, and V/Q scan (D) is for pulmonary embolism.
The client with a mechanical valve replacement asks the nurse, 'Why do I have to take antibiotics before getting my teeth cleaned?' Which response by the nurse is most appropriate?
- A. You are at risk of developing an infection in your heart.'
- B. Your teeth will not bleed as much if you have antibiotics.'
- C. This procedure may cause your valve to malfunction.'
- D. Antibiotics will prevent vegetative growth on your valves.'
Correct Answer: A
Rationale: Mechanical valves increase endocarditis risk; antibiotics (A) prevent heart infection during dental procedures. Bleeding (B), valve malfunction (C), and vegetative growth (D) are inaccurate.
The nurse is administering morning medications. Which medication should be administered first?
- A. The cardiac glycoside medication, digoxin, to a client diagnosed with heart failure and who has 2+ edema of the feet.
- B. The sliding scale insulin to a client with a fasting blood glucose of 345 mg/dL who is demanding breakfast.
- C. The loop diuretic, furosemide, to a client with a 24-hour intake of 986 mL and an output of 1,400 mL.
- D. The ARB medication to a client whose blood pressure was reported by the unlicensed assistive personnel as 142/76.
Correct Answer: B
Rationale: Fasting glucose of 345 mg/dL (B) requires immediate insulin to prevent complications, especially before eating. Digoxin (A), furosemide (C), and ARB (D) are less urgent.
The nurse is told in report the client has aortic stenosis. Which anatomical position should the nurse auscultate to assess the murmur?
- A. Second intercostal space, right sternal notch.
- B. Erb's point.
- C. Second intercostal space, left sternal notch.
- D. Fourth intercostal space, left sternal border.
Correct Answer: A
Rationale: Aortic stenosis murmur is best heard at the second intercostal space, right sternal notch (A), where the aortic root is closest. Erb’s point (B), left sternal notch (C), and fourth space (D) are for other murmurs.