Nokea
The nurse is preparing to administer a prescribed dose of digoxin to an infant. The nurse should assess the apical heart rate to ensure it is at least
- A. 70 beats-per-minute
- B. 60 beats-per-minute
- C. 90 beats-per-minute
- D. 50 beats-per-minute
Correct Answer: C
Rationale: For infants, digoxin should be withheld if the apical heart rate is below 90-100 beats per minute to prevent toxicity, so 90 beats per minute is the minimum threshold.
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The nurse is teaching a client who is receiving newly prescribed enalapril. Which of the following information should be a priority for the nurse to include?
- A. This medication may cause you to develop a dry cough.
- B. If you notice swelling of your face, lips, or eyes, report this to your doctor.
- C. You may notice that the taste of foods is different.
- D. You will need to obtain periodic lab work while taking this medication.
Correct Answer: B
Rationale: Enalapril, an ACE inhibitor, can cause angioedema, a potentially life-threatening swelling of the face, lips, or eyes, making this the priority teaching point. Dry cough, taste changes, and lab monitoring are relevant but less urgent.
This nurse is caring for a client who is receiving prescribed hydralazine. Which of the following findings would indicate a therapeutic response?
- A. Blood pressure 120/70 mm Hg
- B. Pulse (P) 67/minute
- C. Total cholesterol 185 mg/dL [200 mg/dL]
- D. aPTT 45 seconds [30-40 seconds]
Correct Answer: A
Rationale: Hydralazine, a vasodilator, lowers blood pressure, so 120/70 mm Hg indicates a therapeutic response. Pulse, cholesterol, and aPTT are not directly affected.
The emergency department (ED) nurse is caring for a client with a hypertensive emergency. The nurse should obtain a prescription for intravenous
- A. dobutamine
- B. digoxin
- C. nicardipine
- D. amiodarone
Correct Answer: C
Rationale: Nicardipine, an IV calcium channel blocker, is used to rapidly lower blood pressure in a hypertensive emergency. Dobutamine (an inotrope), digoxin (a cardiac glycoside), and amiodarone (an antiarrhythmic) are not appropriate for this condition.
The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is caring for a client with septic shock
Item 1 of 1
Nurses' Notes
1400: Follow-up assessment after the infusion of 30 mL/kg of 0.9% saline bolus (1850 mL total) was infused. Vital signs: T 103.4° F (39.7° C), P 104, RR 22, BP 90/61, pulse oximetry reading 95% on room air.
1410: The physician was notified of the vital signs, and a verbal order for a dopamine drip was received for 5 mcg/kg/minute to titrate to a MAP of 65 mm Hg. The order was read back and verified.
1415: Dopamine infusion started in the client's right antecubital peripheral vascular access device.
1445: The client reports 'stinging' pain at the vascular access site. The site had erythema, swelling, and tenderness when touched. The infusion was stopped.
The nurse reviewed all nursing note entries and notified the physician of the vascular access device assessment findings. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress
- A. Obtain a prescription for phentolamine, Flush the vascular access device, Aspirate any residual medication, Restart the infusion at a lower rate.
- B. Extravasation, Hematoma, Infiltration, Phlebitis.
- C. Urinary output, Neurovascular status of affected extremity, Drainage at vascular access site, Pain level.
Correct Answer: B, A, C
Rationale: The client is experiencing extravasation (B) due to dopamine causing stinging, erythema, and swelling. Actions include obtaining phentolamine (A, an antidote for vasopressor extravasation) and aspirating residual medication (A). Monitor neurovascular status (C) and pain level (C) to assess progress.
A nurse is teaching a client about newly prescribed hydrochlorothiazide (HCTZ). Which of the following statements, if made by the client, indicates an effective understanding of the potential side effects?
- A. I should be cautious about prolonged sun exposure as HCTZ can increase photosensitivity.
- B. I may experience drowsiness and sedation due to the central nervous system depressant effect of HCTZ.
- C. HCTZ can cause hypocalcemia, so I need to increase my intake of foods high in calcium.
- D. I might develop taste disturbances or loss of appetite as a common side effect of HCTZ.
Correct Answer: A
Rationale: HCTZ can cause photosensitivity, increasing the risk of sunburn, so caution with sun exposure indicates correct understanding. HCTZ does not typically cause drowsiness, hypocalcemia, or taste disturbances.