Nokea
The nurse is preparing to administer a beta blocker to a client with hypertension. What is the priority assessment?
- A. Check the client's heart rate.
- B. Check the client's blood pressure.
- C. Check the client's respiratory rate.
- D. Check the client's temperature.
Correct Answer: B
Rationale: The correct answer is B: Check the client's blood pressure. When administering a beta blocker to a client with hypertension, the priority assessment is to check the client's blood pressure. Beta blockers lower blood pressure, so monitoring it before administration helps ensure it is within the safe range. Checking the client's heart rate (choice A) is important but not the priority in this scenario. Respiratory rate (choice C) and temperature (choice D) are not directly related to the administration of beta blockers for hypertension.
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The healthcare provider is monitoring a client receiving lidocaine IV. What side effect is the healthcare provider most concerned about?
- A. Severe headache
- B. Nausea and vomiting
- C. Seizures
- D. Tremors
Correct Answer: C
Rationale: The correct answer is C: Seizures. Lidocaine is a local anesthetic that can cause central nervous system toxicity, leading to seizures. This is the most concerning side effect because it can be life-threatening. Severe headache (A) is not typically associated with lidocaine toxicity. Nausea and vomiting (B) are common side effects but not the most concerning. Tremors (D) can occur but are not as serious as seizures in this context.
During a home visit to an 88-year-old patient who is taking digoxin (Lanoxin) 0.25 mg daily to help control the rate of atrial fibrillation, you obtain this assessment information. Which assessment indicates that you need to notify the physician?
- A. The patient's apical pulse is 68 and very irregular.
- B. The patient takes the digoxin with meals.
- C. The patient's vision is becoming 'fuzzy'.
- D. The patient has lung crackles that clear after coughing.
Correct Answer: C
Rationale: Visual disturbances can indicate digoxin toxicity, necessitating physician notification.
The nurse determines that the treatment of heart failure has been successful when the patient experiences
- A. Weight loss and diuresis
- B. Warm skin and less fatigue
- C. Clear lung sounds and decreased heart rate
- D. Absence of chest pain and improved LOC
Correct Answer: C
Rationale: Successful treatment of heart failure is indicated by an absence of symptoms of pulmonary edema and hypoxemia, such as clear lung sounds and a normal heart rate.
The client is on dobutamine. Adverse effects of Dobutrex (dobutamine) include the following: Select all that apply.
- A. Heart failure
- B. Bradycardia
- C. Tachycardia
- D. Respiratory distress
Correct Answer: C
Rationale: Step-by-step rationale:
1. Dobutamine is a beta-1 adrenergic agonist, which increases heart rate.
2. Tachycardia is a common adverse effect due to increased heart rate.
3. Bradycardia is the opposite effect and not expected with dobutamine.
4. Heart failure is a condition that dobutamine is used to treat, not cause.
5. Respiratory distress is not a typical adverse effect of dobutamine.
Summary:
Choice C (Tachycardia) is correct because dobutamine increases heart rate. Choices A, B, and D are incorrect because dobutamine does not cause heart failure, bradycardia, or respiratory distress.
The client asks about side effects of taking digoxin. How does the nurse respond?
- A. Anorexia can be a side effect of digoxin.
- B. Tachycardia can be a side effect of digoxin.
- C. Constipation can be a side effect of digoxin.
- D. Urinary retention can be a side effect of digoxin.
Correct Answer: A
Rationale: The correct answer is A: Anorexia can be a side effect of digoxin. Digoxin is known to cause anorexia due to its impact on the gastrointestinal system. It can lead to nausea, vomiting, and loss of appetite, resulting in anorexia. Tachycardia (choice B) is not a common side effect of digoxin, as it is actually used to treat certain types of arrhythmias. Constipation (choice C) and urinary retention (choice D) are also not typically associated with digoxin use. In summary, anorexia is a known side effect of digoxin, while tachycardia, constipation, and urinary retention are not commonly linked to this medication.