Nokea
The nurse is giving a client an IV bolus of heparin. What is the most important nursing action?
- A. Monitor the client's heart rate.
- B. Check the client's blood pressure.
- C. Check for signs of bleeding.
- D. Monitor the client's respiratory rate.
Correct Answer: A
Rationale: The correct answer is A: Monitor the client's heart rate. When administering an IV bolus of heparin, it is crucial to monitor the client's heart rate because heparin can cause serious side effects such as bleeding and heparin-induced thrombocytopenia, which can lead to changes in heart rate. Checking blood pressure (B) is also important but not as critical as monitoring heart rate. Checking for signs of bleeding (C) is necessary but should be done after monitoring the heart rate. Monitoring the client's respiratory rate (D) is not directly related to heparin administration.
You may also like to solve these questions
Which term refers to the contraction phase of the heart when blood is ejected from the chambers?
- A. Systole
- B. Diastole
- C. Contractility
- D. Afterload
Correct Answer: A
Rationale: The correct answer is A: Systole. During systole, the heart muscle contracts to pump blood out of the chambers. This phase is essential for delivering oxygenated blood to the body. Diastole (B) is the relaxation phase when the heart fills with blood. Contractility (C) refers to the heart's ability to contract, not a specific phase. Afterload (D) is the pressure the heart must pump against to eject blood, not a phase of the cardiac cycle. Therefore, the term that specifically refers to the contraction phase of the heart is systole.
What is the condition where the blood vessels that supply blood to the legs and feet become narrowed or blocked, causing pain and difficulty walking?
- A. Peripheral artery disease
- B. Raynaud's disease
- C. Varicose veins
- D. Pulmonary embolism
Correct Answer: A
Rationale: The correct answer is A: Peripheral artery disease (PAD). PAD is characterized by narrowed or blocked blood vessels in the legs, leading to reduced blood flow, causing pain and difficulty walking (claudication). The narrowing is typically due to atherosclerosis. Raynaud's disease (B) involves spasms of small arteries, causing reduced blood flow to fingers and toes, not legs. Varicose veins (C) are enlarged, twisted veins, not arteries. Pulmonary embolism (D) is a blockage in the lungs' arteries, not the legs.
The client has a prescription for sublingual nitroglycerin. What is the nurse's instruction for how to take this medication during an episode of chest pain?
- A. Take one tablet every 5 minutes, up to three tablets.
- B. Take one tablet every hour until the pain subsides.
- C. Take two tablets immediately if chest pain occurs.
- D. Take one tablet with a full glass of water.
Correct Answer: A
Rationale: The correct answer is A. Sublingual nitroglycerin is taken under the tongue to quickly relieve chest pain. The nurse should instruct the client to take one tablet every 5 minutes during an episode of chest pain, up to a maximum of three tablets. This is because nitroglycerin works rapidly to dilate blood vessels and improve blood flow to the heart, helping to relieve angina symptoms. Taking one tablet every hour or two tablets immediately may not provide adequate relief and could lead to an overdose. Taking the tablet with water is unnecessary as the medication is absorbed through the mucous membranes under the tongue.
What is the accumulation of fatty deposits along the walls of arteries, leading to reduced blood flow?
- A. Atherosclerosis
- B. Arteriosclerosis
- C. Aneurysm
- D. Thrombosis
Correct Answer: A
Rationale: Atherosclerosis is the correct answer because it specifically refers to the accumulation of fatty deposits in arteries, causing reduced blood flow. Arteriosclerosis is a general term for thickening and hardening of arteries, not necessarily due to fatty deposits. Aneurysm is a localized, abnormal dilation of a blood vessel, not related to fatty deposits. Thrombosis is the formation of a blood clot within a blood vessel, not the accumulation of fatty deposits.
The client is on spironolactone (Aldactone) and has a potassium level of 5.9 mEq/L. What is the nurse's priority action?
- A. Hold the spironolactone and notify the healthcare provider.
- B. Administer potassium supplements.
- C. Continue the spironolactone as ordered.
- D. Increase the dose of spironolactone.
Correct Answer: A
Rationale: The correct answer is A: Hold the spironolactone and notify the healthcare provider. Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. With a potassium level of 5.9 mEq/L, the client is at risk for serious complications like cardiac arrhythmias. The priority action is to stop the medication to prevent further elevation of potassium levels and inform the healthcare provider for further management. Administering potassium supplements (B) would worsen the hyperkalemia. Continuing spironolactone (C) or increasing the dose (D) would be inappropriate and potentially harmful in this situation.