Nokea
The nurse is preparing to administer a scheduled dose of enalapril (Vasotec) to a client with hypertension. Before administering the medication, the nurse should check which priority assessment?
- A. Heart rate
- B. Blood pressure
- C. Respiratory rate
- D. Temperature
Correct Answer: B
Rationale: Before administering enalapril, an antihypertensive medication, the nurse should prioritize checking the client's blood pressure. Monitoring blood pressure helps ensure it is at an acceptable level before giving the medication, as enalapril can further lower blood pressure. This assessment is crucial in preventing potential hypotensive episodes and adverse effects associated with excessive blood pressure reduction.
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The client has angina pectoris and is prescribed nitroglycerin patches. What instruction should the nurse provide to the client?
- A. Apply the patch to the chest and leave it in place for 24 hours
- B. Apply the patch to a different site each time to prevent skin irritation
- C. Remove the patch before going to bed to prevent tolerance
- D. Cut the patch in half if experiencing headaches
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The LPN/LVN is assisting in the care of a client with chronic heart failure who is receiving furosemide (Lasix). Which instruction should the nurse reinforce with the client?
- A. Limit your fluid intake to avoid fluid overload.
- B. Increase your potassium intake by eating bananas and oranges.
- C. Weigh yourself once a week to monitor for fluid retention.
- D. Take the medication at night to avoid frequent urination during the day.
Correct Answer: B
Rationale: The correct instruction for the nurse to reinforce with the client is to increase potassium intake by eating bananas and oranges. Furosemide can lead to potassium loss, potentially causing hypokalemia. By increasing potassium intake through diet, the client can help prevent this electrolyte imbalance and maintain overall health.
A client with peripheral artery disease (PAD) complains of pain in the legs while walking. Which instruction should the LPN/LVN reinforce to help alleviate the client's symptoms?
- A. Walk until the pain becomes severe, then rest.
- B. Perform leg exercises while sitting.
- C. Elevate the legs on pillows while resting.
- D. Take frequent breaks and walk shorter distances.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with atrial fibrillation is receiving warfarin (Coumadin). The nurse should monitor which laboratory test to determine the effectiveness of the therapy?
- A. Prothrombin time (PT) and international normalized ratio (INR)
- B. Activated partial thromboplastin time (aPTT)
- C. Complete blood count (CBC)
- D. Fibrinogen level
Correct Answer: A
Rationale: To monitor the effectiveness of warfarin therapy in a client with atrial fibrillation, the nurse should assess the Prothrombin time (PT) and international normalized ratio (INR) levels. These tests help determine the clotting ability of the blood and ensure that the client's anticoagulation levels are within the therapeutic range, reducing the risk of bleeding or clotting complications.
The client with a history of left-sided heart failure is exhibiting increasing shortness of breath and frothy sputum. What is the priority nursing action?
- A. Administer oxygen
- B. Encourage coughing and deep breathing
- C. Place the client in a supine position
- D. Notify the healthcare provider immediately
Correct Answer: A
Rationale: Shortness of breath and frothy sputum are indicative of pulmonary edema, a serious condition that requires immediate intervention to improve oxygenation. Administering oxygen is the priority action to support the client's respiratory function and prevent further deterioration. Oxygen therapy helps increase the oxygen levels in the blood, alleviate respiratory distress, and support vital organ function. Prompt intervention with oxygen can help stabilize the client while further assessments and treatments are initiated.