Nokea
The nurse is caring for a patient with primary pulmonary hypertension (PPH) who is receiving nifedipine. Which of the following findings indicate that the treatment is effective?
- A. BP is less than 140/90 mm Hg
- B. Patient reports decreased exertional dyspnea.
- C. Heart rate is between 60 and 100 beats/minute.
- D. Patient's chest x-ray indicates clear lung fields.
Correct Answer: B
Rationale: Since a major symptom of PPH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor effectiveness of therapy for a patient with PPH. The chest x-ray will show clear lung fields even if the therapy is not effective.
You may also like to solve these questions
The nurse is caring for patients with active tuberculosis (TB) who misuse alcohol and/or are homeless. Which of the following interventions by the nurse will be most effective in ensuring adherence with the treatment regimen?
- A. Educating the patient about the long-term impact of TB on health
- B. Giving the patient written instructions about how to take the medications
- C. Teaching the patient about the high risk for infecting others unless treatment is followed
- D. Arranging for a daily noontime meal at a community centre and giving the medication then
Correct Answer: D
Rationale: Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help to ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients, but are not likely to be as helpful with this patient.
The nurse is caring for a patient who has a steering wheel injury as a result of an automobile accident. Which of the following findings should be of most concern to the nurse during the initial assessment?
- A. Paradoxical chest movement
- B. The complaint of chest wall pain
- C. A heart rate of 110 beats/minute
- D. A large bruised area on the chest
Correct Answer: A
Rationale: Paradoxical chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.
The nurse is caring for a patient with pneumonia has a fever of 38.4 C (101.1 F). Which of the following orders should the nurse implement first?
- A. Administer acetaminophen 650 mg.
- B. Obtain blood and sputum cultures.
- C. Administer ceftriaxone 1 g IV.
- D. Give patient cool compresses.
Correct Answer: B
Rationale: Obtaining cultures before antibiotic administration is critical to identify the causative organism and ensure appropriate treatment. Administering acetaminophen and ceftriaxone are important but should follow culture collection to avoid altering results. Cool compresses are a supportive measure but not the priority.
The nurse is caring for a patient who is hospitalized with active tuberculosis (TB) and the nurse observes a family member who is visiting the patient. Which of the following actions by the visitor should cause the nurse to intervene?
- A. Washes hands before entering the patient's room
- B. Hands the patient a tissue from the box at the bedside
- C. Puts on a surgical face mask before visiting the patient
- D. Brings food from a 'fast-food' restaurant to the patient
Correct Answer: C
Rationale: An N95 mask, rather than a standard surgical mask, should be used when entering the patient's room because the HEPA mask can filter out 100% of small airborne particles. Handwashing before visiting the patient is not necessary, but there is no reason for the nurse to stop the family member from doing this. Because anorexia and weight loss are frequent problems in patients with TB, bringing food from outside the hospital is appropriate. The family member should wash the hands after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue.
The nurse is providing teaching to a patient with pulmonary tuberculosis (TB) regarding the transmission of TB. Which of the following patient actions indicate that the teaching has been effective?
- A. Demonstrates correct use of a nebulizer
- B. Washes dishes and personal items after use.
- C. Covers the mouth and nose when coughing.
- D. Reports daily to the public health department.
Correct Answer: C
Rationale: Covering the mouth and nose will help decrease airborne transmission of TB. The other actions will not be effective in decreasing the spread of TB.