Nokea
The nurse plans to administer a scheduled dose of metoprolol (Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse notes that the client's telemetry pattern shows a second-degree heart block with a ventricular rate of 50. What action should the nurse take?
- A. Administer the Toprol immediately and monitor the client until the heart rate increases.
- B. Provide the dose of Toprol as scheduled and assign a UAP to monitor the client's BP q30 minutes.
- C. Give the Toprol as scheduled if the client's systolic blood pressure reading is greater than 180.
- D. Hold the scheduled dose of Toprol and notify the healthcare provider of the telemetry pattern.
Correct Answer: D
Rationale: In clients with second-degree heart block, beta blockers such as metoprolol (Toprol SR) are contraindicated as they can further decrease the heart rate. Administering metoprolol in this situation can lead to serious complications. The correct action for the nurse to take is to hold the scheduled dose of Toprol and promptly notify the healthcare provider of the telemetry pattern. This ensures patient safety and appropriate management of the cardiac condition. Choices A, B, and C are incorrect because administering Toprol despite the heart block can worsen the condition and pose a risk to the client's health.
You may also like to solve these questions
A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse?
- A. Hypernatremia
- B. Excessive thirst
- C. Elevated heart rate
- D. Poor skin turgor
Correct Answer: A
Rationale: The correct answer is A: Hypernatremia. In a client with Diabetes Insipidus, hypernatremia, an elevated sodium level in the blood, can lead to neurological symptoms such as confusion, seizures, or coma. Immediate intervention is necessary to prevent these serious complications. Excessive thirst (choice B) is a common symptom of Diabetes Insipidus but does not require immediate intervention. Elevated heart rate (choice C) and poor skin turgor (choice D) are important assessments but are not as critical as hypernatremia in this context.
In a client with cirrhosis admitted with ascites and jaundice, which clinical finding requires immediate intervention?
- A. Peripheral edema
- B. Confusion and altered mental status
- C. Increased abdominal girth
- D. Yellowing of the skin
Correct Answer: B
Rationale: Confusion and altered mental status in a client with cirrhosis and associated ascites and jaundice are indicative of hepatic encephalopathy, a serious complication that requires immediate intervention. This condition can progress rapidly and lead to coma if not addressed promptly. Peripheral edema (choice A) and increased abdominal girth (choice C) are common manifestations of fluid retention in cirrhosis but may not require immediate intervention unless severe. Yellowing of the skin (choice D) is a classic sign of jaundice, which is already known in this client and may not necessitate immediate intervention unless associated with other concerning symptoms.
A client with a spinal cord injury is admitted to the ICU. Which nursing intervention is most important to include in this client's plan of care?
- A. Monitor for signs of autonomic dysreflexia.
- B. Implement measures to prevent pressure ulcers.
- C. Perform passive range of motion exercises.
- D. Ensure that the client is turned every two hours.
Correct Answer: A
Rationale: The correct answer is A: Monitor for signs of autonomic dysreflexia. Autonomic dysreflexia is a life-threatening condition that can occur in clients with spinal cord injuries, especially those with injuries above the T6 level. It is characterized by a sudden onset of excessively high blood pressure, pounding headache, profuse sweating, and flushing above the level of injury. Failure to recognize and treat autonomic dysreflexia promptly can lead to seizures, stroke, or even death. Therefore, monitoring for signs of autonomic dysreflexia is crucial in clients with spinal cord injuries. Choices B, C, and D are important interventions too, but in the context of a spinal cord injury, monitoring for autonomic dysreflexia takes priority due to its potentially life-threatening nature.
The nurse is assessing a client with right-sided heart failure. Which finding requires immediate intervention?
- A. Jugular venous distention
- B. Peripheral edema
- C. Crackles in the lungs
- D. Elevated liver enzymes
Correct Answer: C
Rationale: In a client with right-sided heart failure, crackles in the lungs are the most concerning finding as they indicate pulmonary congestion, which requires immediate intervention. Crackles suggest fluid accumulation in the lungs, leading to impaired gas exchange and potential respiratory distress. Jugular venous distention (Choice A) and peripheral edema (Choice B) are common findings in right-sided heart failure but do not indicate acute deterioration requiring immediate intervention. Elevated liver enzymes (Choice D) may be seen in chronic heart failure but do not warrant immediate action compared to the urgent need to address pulmonary congestion indicated by crackles in the lungs.
The nurse is assessing a primigravida at 39-weeks gestation during a weekly prenatal visit. Which finding is most important for the nurse to report to the healthcare provider?
- A. Fetal heart rate of 200 beats/minute.
- B. Mild ankle edema.
- C. Complaints of back pain.
- D. Decreased fetal movements.
Correct Answer: A
Rationale: A fetal heart rate of 200 beats per minute is significantly elevated and requires immediate medical attention. This finding could indicate fetal distress, tachycardia, or other serious issues that need prompt evaluation. Mild ankle edema, complaints of back pain, and decreased fetal movements are common in pregnancy but are not as urgent or concerning as a high fetal heart rate.