Nokea
The nurse is administering nitroglycerin IV to a client with chest pain. What is the most important parameter to monitor?
- A. Blood pressure
- B. Heart rate
- C. Oxygen saturation
- D. Respiratory rate
Correct Answer: A
Rationale: The correct answer is A: Blood pressure. When administering nitroglycerin IV for chest pain, monitoring blood pressure is crucial as it can drop significantly, leading to hypotension. This can cause further complications. Heart rate may increase initially due to vasodilation, but it's not the most important parameter. Oxygen saturation and respiratory rate are also important but monitoring blood pressure takes precedence in this situation.
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What is an infection that causes inflammation in the air sacs of one or both lungs, which may fill with fluid or pus?
- A. Pneumonia
- B. Tuberculosis
- C. Pleurisy
- D. Pulmonary edema
Correct Answer: A
Rationale: The correct answer is A: Pneumonia. Pneumonia is an infection that causes inflammation in the air sacs of the lungs, leading to fluid or pus accumulation. This is a common respiratory condition characterized by symptoms such as cough, fever, and difficulty breathing. Pleurisy (C) is inflammation of the pleura surrounding the lungs, not the air sacs. Tuberculosis (B) is a bacterial infection affecting the lungs but does not specifically mention inflammation and pus in the air sacs. Pulmonary edema (D) is the accumulation of fluid in the lungs but is not caused by an infection like pneumonia.
The client on warfarin has an INR of 4.5. What is the most appropriate action by the nurse?
- A. Administer vitamin K.
- B. Hold the next dose of warfarin.
- C. Increase the dose of warfarin.
- D. Monitor the client's INR closely.
Correct Answer: A
Rationale: The correct answer is A: Administer vitamin K. When a client on warfarin has an INR of 4.5, it indicates over-anticoagulation, putting them at risk of bleeding. Vitamin K helps reverse the effects of warfarin by promoting clotting factors. Administering vitamin K will lower the INR back into the therapeutic range. Holding the next dose of warfarin (B) is not enough to rapidly reverse the effects. Increasing the dose of warfarin (C) would worsen the over-anticoagulation. Monitoring the INR closely (D) is important but not the immediate action needed for a high INR.
Which disease is characterized by the damage to the alveoli in the lungs, leading to breathlessness?
- A. Emphysema
- B. Pulmonary fibrosis
- C. Lung cancer
- D. Lung abscess
Correct Answer: A
Rationale: The correct answer is A: Emphysema. This disease is characterized by the destruction of alveoli, leading to breathlessness. Emphysema is typically caused by smoking, resulting in the breakdown of lung tissue and reduced oxygen exchange. Pulmonary fibrosis (B) involves scarring of lung tissue, not alveolar damage. Lung cancer (C) is characterized by the growth of abnormal cells in the lung, not alveolar destruction. Lung abscess (D) is a localized infection in the lung, not related to alveolar damage causing breathlessness.
The nurse is caring for a client on digoxin. What is the most important assessment before administering this medication?
- A. Check the client's heart rate.
- B. Check the client's blood pressure.
- C. Check the client's respiratory rate.
- D. Check the client's oxygen saturation.
Correct Answer: A
Rationale: The correct answer is A: Check the client's heart rate. Before administering digoxin, it is crucial to assess the client's heart rate as digoxin can cause bradycardia or arrhythmias. Monitoring the heart rate helps to determine if the client is at risk of experiencing these adverse effects. Checking blood pressure, respiratory rate, or oxygen saturation is important but not as crucial as assessing the heart rate when administering digoxin. Bradycardia is a common adverse effect of digoxin, so assessing the heart rate is the priority.
Nurse's role in management of client with permanent pacemaker implant.
- A. Monitoring
- B. Education
- C. Both A and B
- D. None of the above
Correct Answer: C
Rationale: Nurses monitor device function and educate patients about care.