Nokea
The nurse is caring for a client with a history of atrial fibrillation who is prescribed amiodarone (Cordarone). Which of the following side effects should the nurse monitor for?
- A. Pulmonary toxicity.
- B. Hyperglycemia.
- C. Weight gain.
- D. Hair loss.
Correct Answer: A
Rationale: Amiodarone can cause pulmonary toxicity, a serious side effect requiring regular monitoring of lung function.
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The nurse is caring for a client who has just undergone a pacemaker insertion. Which of the following instructions should the nurse include in the discharge teaching?
- A. Avoid lifting heavy objects for 4-6 weeks.
- B. Resume driving immediately.
- C. Use a microwave oven without restrictions.
- D. Avoid cell phone use permanently.
Correct Answer: A
Rationale: Avoiding heavy lifting for 4-6 weeks prevents dislodgement of the pacemaker leads during healing.
A child's plan of care lists increasing protein intake as a goal. Which of the following foods that the child likes should the nurse encourage the child to eat?
- A. A bacon, lettuce, and tomato sandwich.
- B. Fruit-flavored yogurt.
- C. Nacho chips and salsa.
- D. Crackers with butter and jelly.
Correct Answer: B
Rationale: Fruit-flavored yogurt is a good source of protein, suitable for increasing protein intake in a child's diet.
A client with a history of atrial fibrillation is admitted with a heart rate of 160 beats per minute. The nurse should prioritize which of the following interventions?
- A. Administer diltiazem as prescribed.
- B. Obtain a 12-lead ECG.
- C. Administer aspirin.
- D. Apply oxygen via nasal cannula.
Correct Answer: A
Rationale: Diltiazem, a calcium channel blocker, is prioritized to control rapid heart rate in atrial fibrillation.
A client is scheduled to have surgery. The nurse should place priority on determining whether the surgeon wants which medications held in the preoperative period to assure client safety?
- A. Warfarin
- B. Furosemide
- C. Famotidine
- D. Multivitamin with minerals
Correct Answer: A
Rationale: The nurse is careful to question the surgeon about whether warfarin should be administered in the preoperative period. This medication is often withheld for a period of time preoperatively to minimize the risk of hemorrhage during surgery. The other medications may also be withheld if specifically prescribed, but usually they are discontinued as part of an NPO (nothing by mouth) after midnight prescription.
A client being mechanically ventilated after experiencing a fat embolus is visibly anxious. Which action should the nurse take?
- A. Remain with the client and provide reassurance.
- B. Ask a family member to stay with the client at all times.
- C. Encourage the client to sleep until arterial blood gas results improve.
- D. Ask the primary health care provider to write a prescription for an antianxiety medication.
Correct Answer: A
Rationale: The nurse always speaks to the client calmly and provides reassurance to the anxious client. Family members are also stressed because of the severity of the situation; therefore, it is not beneficial to ask the family to take on the burden of remaining with the client at all times. Encouraging the client to sleep will not assist in relieving the client's anxiety. Antianxiety medications are used only if necessary and if other interventions fail to relieve the client's anxiety.