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The nurse is caring for a client on heparin. What is the most important lab value to monitor?
- A. aPTT
- B. INR
- C. Platelet count
- D. Hemoglobin
Correct Answer: A
Rationale: The correct answer is A: aPTT. This lab value is crucial for monitoring heparin therapy as it measures the effectiveness of the medication in preventing blood clots. Monitoring aPTT helps ensure the client is within the therapeutic range to prevent bleeding or clotting complications. Incorrect choices:
B: INR is used to monitor warfarin therapy, not heparin.
C: Platelet count is important, but aPTT is more directly related to heparin therapy.
D: Hemoglobin is important for assessing anemia but not specific to monitoring heparin therapy.
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The nurse is caring for a client on enalapril (Vasotec). What is the most important side effect to monitor?
- A. Cough
- B. Hyperkalemia
- C. Hypotension
- D. Dizziness
Correct Answer: A
Rationale: The correct answer is A: Cough. Enalapril is an ACE inhibitor that can cause a dry, persistent cough as a common side effect. It is important to monitor for this because it can indicate a potentially serious adverse reaction called angioedema. Hyperkalemia (B) is a possible side effect of enalapril but is typically not as urgent to monitor as cough. Hypotension (C) is a common side effect but is usually monitored during the initial dose titration. Dizziness (D) is a less common side effect and is often transient. Monitoring for cough is crucial to detect and manage any potential angioedema promptly.
What is a condition where the heart muscle is weakened and unable to pump blood effectively, often leading to heart failure?
- A. Cardiomyopathy
- B. Myocarditis
- C. Endocarditis
- D. Pericarditis
Correct Answer: A
Rationale: The correct answer is A: Cardiomyopathy. Cardiomyopathy refers to a condition where the heart muscle is weakened and unable to pump blood effectively, leading to heart failure. This is because the heart muscle becomes enlarged, thickened, or stiff, affecting its ability to pump blood efficiently.
Incorrect choices:
B: Myocarditis - Myocarditis is inflammation of the heart muscle, not necessarily associated with weakening of the heart muscle leading to heart failure.
C: Endocarditis - Endocarditis is inflammation of the inner lining of the heart chambers and valves, not directly related to the weakening of the heart muscle.
D: Pericarditis - Pericarditis is inflammation of the pericardium (the outer lining of the heart), and does not directly involve the weakening of the heart muscle.
What is a condition where blood clots form in the deep veins, usually in the legs, and can travel to the lungs, causing serious complications?
- A. Deep vein thrombosis (DVT)
- B. Pulmonary embolism
- C. Varicose veins
- D. Peripheral artery disease
Correct Answer: A
Rationale: The correct answer is A: Deep vein thrombosis (DVT). DVT is a condition where blood clots form in the deep veins, typically in the legs. These clots can dislodge and travel to the lungs, leading to a pulmonary embolism. Choice B, pulmonary embolism, is a complication of DVT, not the initial condition. Varicose veins (C) are enlarged, twisted veins usually visible on the skin surface, not deep veins. Peripheral artery disease (D) involves narrowed arteries, not blood clots in veins.
The client on spironolactone (Aldactone) should avoid which type of food?
- A. Foods high in potassium
- B. Foods high in sodium
- C. Foods high in calcium
- D. Foods high in chloride
Correct Answer: A
Rationale: The correct answer is A: Foods high in potassium. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium. Consuming foods high in potassium while on spironolactone can lead to hyperkalemia, which is an elevated level of potassium in the blood. This can result in serious health complications such as irregular heartbeats and muscle weakness. Therefore, it is crucial for clients on spironolactone to avoid foods high in potassium to prevent these adverse effects. Choices B, C, and D are incorrect because spironolactone does not specifically interact with sodium, calcium, or chloride in a way that necessitates avoiding foods high in these electrolytes.
If Mrs. Jones has a temporary pacemaker and the pacemaker intermittently fails to capture or sense, increasing the output temporarily restores function. Failure to capture or sense appropriately is most often due to
- A. Prior emergency defibrillation for ventricular failure
- B. Dislodgment of pacing electrode from right ventricle
- C. Occurrence of frequent ectopic beats from right ventricle
- D. Perforation to the right ventricle by pacing electrode
Correct Answer: B
Rationale: Dislodgment affects proper pacemaker function.