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The nurse is caring for a client following a femoral angiography. When developing this client's plan of care, the nurse plans to
- A. encourage the client to ambulate within one hour following this procedure.
- B. discontinue prescribed intravenous fluids immediately after the procedure
- C. assess kidney function via lab testing on the day following the procedure.
- D. maintain nothing by mouth (NPO) status for 4 hours following the procedure.
Correct Answer: C
Rationale: Femoral angiography involves contrast dye, which can affect kidney function. Monitoring renal function via lab tests (e.g., creatinine) post-procedure is essential to detect contrast-induced nephropathy.
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The nurse is caring for a client who has just been diagnosed with acute pericarditis. Which of the following medications should the nurse anticipate the primary health care provider (PHCP) will prescribe?
- A. isoniazid
- B. colchicine
- C. allopurinol
- D. warfarin
Correct Answer: B
Rationale: Colchicine is used to reduce inflammation in acute pericarditis, often combined with NSAIDs.
The nurse is assisting a physician in performing a bronchoscopy. The nurse suspects the client is experiencing a vasovagal response as evidence by the client's
- A. hypertension.
- B. bronchodilation.
- C. increase in heart rate (HR).
- D. decrease in heart rate (HR).
Correct Answer: D
Rationale: A vasovagal response causes bradycardia due to vagal nerve stimulation during procedures like bronchoscopy.
The nurse has taught a client newly prescribed sublingual nitroglycerin for acute angina. Which of the following statements by the client would require follow-up?
- A. I will get a refill of my prescription every six months.
- B. I will take one tablet every 2 minutes if chest pain occurs.
- C. I will place my medication in a dark amber bottle.
- D. I must not chew on the tablet when taking it.
Correct Answer: B
Rationale: Nitroglycerin should be taken every 5 minutes (up to 3 doses) for chest pain, not every 2 minutes, to avoid overdose.
Which of the following interventions should the nurse implement to manage fluid volume overload in a client with heart failure? Select all that apply.
- A. Administer diuretics as prescribed
- B. Monitor daily weights
- C. Restrict fluid intake to 500 mL per day
- D. Assess lung sounds for crackles
- E. Encourage high-sodium diet
- F. Assess lung sounds for rhonchi
Correct Answer: A,B,D
Rationale: Diuretics reduce fluid overload. Daily weights monitor fluid status. C: Incorrect - 500 mL/day is too restrictive; 1.5-2 L is typical. D: Correct - Crackles indicate pulmonary edema. E: Incorrect - High-sodium diets worsen fluid retention. F: Incorrect - Rhonchi are not specific to fluid overload.
Which of the following information should the nurse include when teaching a client about congestive heart failure (CHF)? Select all that apply.
- A. Foods such as canned vegetables and luncheon meat should be avoided.
- B. Weigh yourself daily and notify the physician if the weight gain is more than ten pounds in a week.
- C. You may continue to take ibuprofen for your aches and pains.
- D. Annual immunizations such as the influenza vaccine are recommended.
- E. If you feel sick, you will need to check your urine for ketones.
Correct Answer: A,D
Rationale: High-sodium foods like canned vegetables and luncheon meat should be avoided to prevent fluid retention. B: Incorrect - Weight gain >2-3 lbs in a week is concerning, not 10 lbs. C: Incorrect - Ibuprofen can worsen heart failure. D: Correct - Influenza vaccine reduces infection risk, which can exacerbate heart failure. E: Incorrect - Checking urine for ketones is relevant for diabetes, not CHF.