Nokea
The nurse is preparing to administer medications to a client admitted with atrial fibrillation. The nurse notes the vital signs shown in the exhibit. Which medications due at this time are safe to administer? Select all that apply.
- A. Diltiazem extended-release PO
- B. Heparin subcutaneous injection
- C. Lisinopril PO
- D. Metoprolol PO
- E. Timolol ophthalmic
Correct Answer: A,B,E
Rationale: Without specific vital signs, diltiazem (rate control), heparin (anticoagulation), and timolol (glaucoma, not cardiac) are generally safe in atrial fibrillation unless contraindicated (e.g., severe hypotension). Lisinopril and metoprolol require caution if hypotensive or bradycardic, but no exhibit data suggests otherwise.
You may also like to solve these questions
The licensed practical nurse is monitoring a client receiving an IV of Nipride in D5W. The IV bag has a foil covering, and the nurse notes that the IV fluid has a light brownish tint. The nurse should:
- A. Discard the solution.
- B. Obtain a bag of normal saline.
- C. Cover both the solution bag and the IV tubing with foil.
- D. Do nothing because the solution is expected to be light brown in color.
Correct Answer: D
Rationale: Nipride (nitroprusside) is light-sensitive and turns light brown, which is normal if protected by foil. No action is needed.
The nurse in the outpatient clinic is speaking with a client diagnosed with cerebral arteriovenous malformation. Which statement would be a priority for the nurse to report to the health care provider?
- A. I got short of breath this morning when I worked out
- B. I have cut down on smoking to ½ pack per day
- C. I haven't been feeling well, so I have been sleeping a lot.
- D. I took an acetaminophen in the waiting room for this bad headache.
Correct Answer: D
Rationale: A bad headache in a client with cerebral arteriovenous malformation may indicate increased intracranial pressure or bleeding, requiring urgent reporting. Other symptoms are less specific and less immediately critical.
The nurse is caring for a client who underwent a transsphenoidal hypophysectomy to remove a pituitary adenoma. Which of the following interventions should the nurse implement? Select all that apply.
- A. Encourage frequent coughing to prevent pneumonia
- B. Inspect the mouth and perform mouth care every 4 hours
- C. Maintain the head of the bed in a flat position
- D. Perform frequent neurologic checks
- E. Remind the client to avoid using a toothbrush for 10 days
Correct Answer: B,D,E
Rationale: Mouth care prevents infection, neurologic checks monitor for complications (e.g., CSF leak), and avoiding toothbrushing prevents suture disruption. Coughing risks increasing intracranial pressure, and the head of the bed should be elevated to reduce pressure.
The nurse is caring for a 2 year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects?
- A. Neurotoxicity
- B. Hepatomegaly
- C. Nephrotoxicity
- D. Ototoxicity
Correct Answer: C
Rationale: Nephrotoxicity. Nephrotoxicity is a common side effect of calcium disodium edetate, in addition to lead poisoning in general.
The nurse is reinforcing teaching about ulcer prevention with a client newly diagnosed with peptic ulcer disease. Which of the following client statements indicate appropriate understanding of teaching? Select all that apply.
- A. I need to avoid taking medicines like ibuprofen without a prescription.
- B. I should avoid drinking excess coffee or cola.
- C. I should enroll in a smoking cessation program.
- D. I should reduce or eliminate my intake of alcoholic beverages.
- E. I will eliminate whole wheat foods, like breads and cereals, from my diet.
Correct Answer: A,B,C,D
Rationale: Avoiding NSAIDs (ibuprofen), excess coffee/cola, smoking, and alcohol reduces ulcer irritation and promotes healing. Whole wheat foods are beneficial for digestion and not contraindicated.