Nokea
The nurse is caring for a client receiving a continuous infusion of diltiazem who has the below tracing on the electrocardiogram (ECG). On assessment, the client has irregular peripheral pulses, an S3 heart sound, and 2+ pedal edema. The nurse should plan to take which priority action? See the image below.
- A. Assess the client for chest pain
- B. Perform a 12-lead electrocardiogram
- C. Stop the infusion
- D. Obtain an immediate troponin level
Correct Answer: C
Rationale: S3 and edema suggest heart failure, possibly exacerbated by diltiazem's negative inotropic effect. Stopping the infusion is the priority.
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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.
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.
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 the primary health care provider (PHCP) with an elective electrical cardioversion for a chronic atrial fibrillation client. Prior to this procedure, the nurse should perform which action?
- A. Remove the client's peripheral vascular access device.
- B. Review the client's risk factors for post-procedure bleeding.
- C. Ensure that a water-seal chest tube drainage device is readily available.
- D. Verify that the informed consent has been obtained by the health care provider (HCP).
Correct Answer: D
Rationale: Informed consent is required for elective cardioversion, a procedure with risks like thromboembolism.
The nurse performs a physical assessment on a client with infective endocarditis (IE). The nurse observes flat, reddened non-tender maculae on the hands and feet. The nurse understands that these are
- A. Heberden's nodes
- B. Janeway lesions
- C. Tophi
- D. Bouchard's nodes
Correct Answer: B
Rationale: Janeway lesions are non-tender, erythematous maculae on the palms and soles, characteristic of infective endocarditis.