Nokea
The nurse is caring for a client who has undergone a coronary artery bypass graft (CABG) surgery. Which action should the nurse take to prevent postoperative complications?
- A. Encourage the client to cough and deep breathe every 1 to 2 hours.
- B. Maintain the client in a supine position at all times.
- C. Keep the client on bed rest for the first 48 hours.
- D. Restrict the client's fluid intake to prevent overload.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The LPN/LVN is assisting in the care of a client with chronic heart failure who is receiving furosemide (Lasix). Which instruction should the nurse reinforce with the client?
- A. Limit your fluid intake to avoid fluid overload.
- B. Increase your potassium intake by eating bananas and oranges.
- C. Weigh yourself once a week to monitor for fluid retention.
- D. Take the medication at night to avoid frequent urination during the day.
Correct Answer: B
Rationale: The correct instruction for the nurse to reinforce with the client is to increase potassium intake by eating bananas and oranges. Furosemide can lead to potassium loss, potentially causing hypokalemia. By increasing potassium intake through diet, the client can help prevent this electrolyte imbalance and maintain overall health.
A client with a history of myocardial infarction (MI) is being discharged with a prescription for nitroglycerin sublingual tablets. Which instruction should the nurse reinforce?
- A. Store the tablets in a cool, dry place away from light.
- B. Take a tablet every 5 minutes if chest pain occurs.
- C. Place the tablets under the tongue for sublingual absorption.
- D. Take the tablets without water for faster effect.
Correct Answer: A
Rationale: Nitroglycerin tablets are light and moisture-sensitive, so they should be stored in a cool, dry place away from light to maintain their effectiveness. Option B advises taking a tablet every 5 minutes, which may lead to overdose. Option C emphasizes the correct administration route for sublingual tablets. Option D is incorrect as water is not needed for the tablets to take effect.
A client with a diagnosis of acute myocardial infarction (MI) is receiving thrombolytic therapy. The nurse monitors the client for which potential complication associated with this therapy?
- A. Hypertension
- B. Bleeding
- C. Hyperkalemia
- D. Hypoglycemia
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is preparing to administer a scheduled dose of enalapril (Vasotec) to a client with hypertension. Before administering the medication, the nurse should check which priority assessment?
- A. Heart rate
- B. Blood pressure
- C. Respiratory rate
- D. Temperature
Correct Answer: B
Rationale: Before administering enalapril, an antihypertensive medication, the nurse should prioritize checking the client's blood pressure. Monitoring blood pressure helps ensure it is at an acceptable level before giving the medication, as enalapril can further lower blood pressure. This assessment is crucial in preventing potential hypotensive episodes and adverse effects associated with excessive blood pressure reduction.
A client with a history of deep vein thrombosis (DVT) is prescribed warfarin (Coumadin). The nurse should include which instruction in the discharge teaching?
- A. Take the medication at the same time each day
- B. Avoid green leafy vegetables in your diet
- C. Increase your intake of vitamin K-rich foods
- D. Stop the medication if you notice any bruising
Correct Answer: A
Rationale: Taking warfarin at the same time each day is crucial to maintain consistent blood levels and ensure the effectiveness of the medication in preventing clot formation. Consistent timing helps in monitoring and adjusting the dosage as needed to keep the international normalized ratio (INR) within the therapeutic range to prevent clotting events or excessive bleeding.