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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A client is scheduled for a coronary artery bypass graft (CABG) surgery. The nurse should prepare the client by reinforcing information about which post-operative care measure?
- A. You will be on bed rest for the first 48 hours after surgery.
- B. You will be encouraged to cough and deep breathe frequently.
- C. You will be discharged within 24 hours if no complications arise.
- D. You will not be able to eat or drink for 24 hours after surgery.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client has angina pectoris and is prescribed nitroglycerin patches. What instruction should the nurse provide to the client?
- A. Apply the patch to the chest and leave it in place for 24 hours
- B. Apply the patch to a different site each time to prevent skin irritation
- C. Remove the patch before going to bed to prevent tolerance
- D. Cut the patch in half if experiencing headaches
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The LPN/LVN is assisting in the care of a client with a diagnosis of heart failure who is receiving digoxin (Lanoxin). Which laboratory result should the nurse monitor closely?
- A. Serum sodium
- B. Serum potassium
- C. Serum calcium
- D. Serum glucose
Correct Answer: B
Rationale: The correct answer is serum potassium. Monitoring serum potassium levels is crucial when a client is receiving digoxin (Lanoxin) because low potassium levels can increase the risk of digoxin toxicity. Digoxin and low potassium levels can lead to serious cardiac complications, such as arrhythmias. Therefore, close monitoring of serum potassium is essential to prevent adverse effects and ensure the safe administration of digoxin in clients with heart failure.
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.
A client with a history of heart failure is prescribed metoprolol (Lopressor). The nurse should monitor the client for which common side effect of this medication?
- A. Tachycardia
- B. Hypotension
- C. Hypertension
- D. Hyperglycemia
Correct Answer: B
Rationale: Metoprolol is a beta-blocker commonly used in heart failure to reduce blood pressure. One of the common side effects of metoprolol is hypotension, which can lead to dizziness, lightheadedness, and even fainting. Therefore, monitoring for hypotension is essential to prevent adverse effects and ensure patient safety.