Nokea
The nurse is caring for a client with the below tracing on the electrocardiogram. The nurse should perform which priority action? See the image below.
- A. initiate a code blue.
- B. establish a peripheral vascular access device
- C. notify the primary healthcare physician (PHCP)
- D. assess the client's airway, breathing, and circulation
Correct Answer: D
Rationale: For any critical ECG tracing (e.g., ventricular fibrillation), assessing airway, breathing, and circulation (ABCs) is the priority to guide further interventions.
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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 emergency department nurse is caring for a client with congestive heart failure who reports dyspnea and a persistent cough. The nurse obtains the client's vital signs and suspects that the client is experiencing which condition? See the image below.
- A. Pulmonary embolism
- B. Hypovolemic shock
- C. Disseminated intravascular coagulation (DIC)
- D. Pulmonary edema
Correct Answer: D
Rationale: Dyspnea and persistent cough in CHF suggest pulmonary edema due to fluid backup in the lungs.
The following scenario applies to the next 1 items
The nurse in the outpatient clinic is caring for a 37-year-old male client
Item 1 of 1
Nurses' Note Physician Orders Current Medications
1100: The client reports intermittent dizziness that started following the dosage increase of his prescribed spironolactone one week ago. The client states that it is worse for a few hours after he takes the medication but then resolves. On assessment, the client is alert and oriented. The client's breathing is unlabored and has clear lung fields bilaterally. Skin warm to the touch and pink in tone; pulses 2+ and regular. Capillary refill is 3 seconds. He denies any pain.
Vital signs: T 98.6° F (37° C), P 76, RR 16, BP 130/86, pulse oximetry reading 98% on room air. Medical history of hypertension and hyperlipidemia.
The nurse prepares to obtain the client's orthostatic blood pressure (BP) by first positioning the client …………. then positioning the client …………. the client …………. When obtaining the blood pressure, the nurse should ……………….. The nurse should be concerned for orthostatic hypotension if the systolic blood pressure decreases by ………….. or the diastolic blood pressure decreases by……………….
- A. Standing
- B. Supine
- C. Sitting
- D. Obtain the blood pressure with the client's arm in the dependent position.
- E. Keep the blood pressure cuff in the same position.
- F. Obtain BP readings 10 minutes after the client changes position.
- G. 20 mm Hg
Correct Answer: B,C,A,E,G
Rationale: Orthostatic BP is measured supine (B), then sitting (C), then standing (A). The cuff should stay in the same position (E). A drop of 20 mm Hg systolic (G) or 10 mm Hg diastolic
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.
The nurse is assessing a client with systolic heart failure. Which of the following would be an expected finding of right-sided heart failure?
- A. ascites
- B. tachypnea
- C. cough
- D. orthopnea
Correct Answer: A
Rationale: Right-sided heart failure causes systemic congestion, leading to ascites due to fluid accumulation in the abdomen.