Nokea
The nurse is caring for a client with myocardial infarction (MI), who is receiving tissue plasminogen activator (tPA), the nurse should plan to prioritize which of the following?
- A. Observe for neurological changes
- B. Monitor for any signs of renal failure
- C. Observe for signs of bleeding
- D. Check the client's food diary
Correct Answer: C
Rationale: tPA is a thrombolytic that increases bleeding risk. Monitoring for signs of bleeding (e.g., hematoma, gastrointestinal bleeding) is critical.
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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 following scenario applies to the next 6 items
The client is a 72-year-old male who presents to the emergency department with increasing
shortness of breath over the past two days that gets worse when he is lying flat in bed at night.
Item 1 of 6
History And Physical Nurses' Notes Flow Sheet
0700: The client is a 72-year-old male who presents to the emergency department with increasing shortness of breath over the past two days that gets worse when he is lying flat in bed at night. He states, "I feel like I can't catch my breath," and he had to sleep in a recliner. He reports a 4 lb weight gain over the last week and increasing fatigue. The client is alert and oriented but is using his accessory muscles to breathe. He reports feeling short of breath, orthopnea, and paroxysmal nocturnal dyspnea. He has bilateral pedal edema (+2), bilateral crackles heard upon auscultation, and jugular vein distention noted on his assessment. The
the client has a medical history of hypertension, coronary artery disease, and a prior myocardial infarction. He was diagnosed with heart failure with reduced ejection fraction (HFrEF) two years ago. Current home medications include lisinopril, metoprolol succinate, furosemide, and atorvastatin.
For each medication, choose the most likely option for drug classification and mechanism of action for heart failure: Spironolactone, Sacubitril/Valsartan, Dapagliflozin
- A. Spironolactone: MRA, Blocks aldosterone effects
- B. Sacubitril/Valsartan: ARNI, Blocks RAAS and neprilysin
- C. Dapagliflozin: SGLT2 inhibitor, Causes osmotic diuresis
Correct Answer: A,B,C
Rationale: Spironolactone: MRA (Mineralocorticoid Receptor Antagonist) blocks aldosterone, reducing fluid retention. Sacubitril/Valsartan: ARNI blocks RAAS and neprilysin, improving vasodilation and diuresis. Dapagliflozin: SGLT2 inhibitor causes osmotic diuresis, reducing fluid overload.
The nurse is caring for a client who is reporting pain in their left lower leg. How should the nurse assess for the presence of thrombophlebitis?
- A. By palpating the skin over the tibia and fibula
- B. By documenting daily calf circumference measurements
- C. By recording vital signs obtained four times a day
- D. By noting difficulty with ambulation
Correct Answer: B
Rationale: Measuring calf circumference detects swelling, a key sign of thrombophlebitis, indicating possible deep vein thrombosis.
Which of the following statements by the client with atrial fibrillation would require a follow-up? Select all that apply.
- A. I have an increased risk for a stroke.
- B. I should weigh myself daily at the same time.
- C. I may be prescribed medications such as amiodarone.
- D. I should wear a mask when I am in public.
- E. I should seek medical care if I develop shortness of breath.
Correct Answer: B,D
Rationale: Atrial fibrillation increases stroke risk due to clot formation; no follow-up needed. B: Incorrect - Daily weighing is more relevant for heart failure, not atrial fibrillation; requires clarification. C: Correct - Amiodarone is a common medication for atrial fibrillation; no follow-up needed. D: Incorrect - Wearing a mask in public is not related to atrial fibrillation management; requires clarification. E: Correct - Shortness of breath could indicate complications; no follow-up needed.
The nurse reviews the client's continuous telemetry monitor and observes the following. As the nurse reviews the client's current medications, which prescribed medication is most likely causing this tracing? See the image below.
- A. losartan
- B. nitroglycerin transdermal patch
- C. enalapril
- D. verapamil
Correct Answer: D
Rationale: Verapamil, a calcium channel blocker, can cause bradycardia or heart block, potentially leading to abnormal ECG tracings.