Nokea
The nurse reviews a client's lipid panel who is being treated for hyperlipidemia with simvastatin. Which of the following actions should the nurse take based on the results? See the results in the exhibit.
- A. Review the client's most recent creatinine
- B. Assess the client's adherence to the prescribed medication
- C. Determine if the client is adhering to a low salt diet
- D. Document the results as within normal limits
Correct Answer: B
Rationale: If lipid panel results are abnormal, assessing adherence to simvastatin is key, as non-compliance may explain ineffective treatment.
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The nurse is caring for a client with congestive heart failure experiencing an exacerbation. Which of the following of the client's vital signs would indicate that the client is experiencing a complication?
- A. Decrease in blood pressure
- B. Increase in temperature
- C. Decrease in respiratory rate
- D. Increase in blood pressure
Correct Answer: A
Rationale: A decrease in blood pressure during a CHF exacerbation may indicate cardiogenic shock, a serious complication.
The nurse is assessing a client with congestive heart failure. Which physical assessment finding should the nurse expect?
- A. Intermittent claudication
- B. S3 gallop
- C. Venous stasis ulcers
- D. Widened pulse pressure
Correct Answer: B
Rationale: An S3 gallop is a common finding in CHF, indicating fluid overload and ventricular dysfunction.
The following scenario applies to the next 1 items
The nurse cares for a client following a cardiac arrest
Item 1 of 1
Admission Notes
2000 - 36-year-old was found unresponsive and with no pulse after collapsing at his job. Cardiopulmonary resuscitation (CPR) was started at the scene. The client was successfully resuscitated in the emergency department. The client was intubated, and central vascular access was established.
2130 - The client was transferred to the intensive care unit. Shortly after the transfer, the client converted to ventricular fibrillation. Code blue was called. CPR was delivered over 2 minutes, and a palpable carotid pulse was not assessed. The client's current cardiac monitor shows asystole.
The next essential intervention is the administration of…………… followed by ……………….. for a client in asystole post-cardiac arrest.
- A. Epinephrine
- B. Amiodarone
- C. Sodium bicarbonate
- D. Defibrillation
- E. Resuming CPR
- F. Cardioversion
Correct Answer: A,E
Rationale: Epinephrine is given in asystole to stimulate cardiac activity. E: Correct - CPR resumes immediately after medication to restore circulation. B, C, D, F: Incorrect - Amiodarone, sodium bicarbonate, defibrillation, and cardioversion are not indicated for asystole.
The nurse is caring for a client with a myocardial infarction experiencing tachycardia and coughing up frothy, pink-tinged sputum. Which finding would the nurse expect upon lung auscultation?
- A. Wheezing
- B. Crackles
- C. Rhonchi
- D. Diminished sounds
Correct Answer: B
Rationale: Frothy, pink-tinged sputum indicates pulmonary edema, often post-MI, causing crackles on lung auscultation due to fluid in alveoli.
The nurse is discussing cardiac dysrhythmias with a student. Which of the following statements, if made by the student, would indicate effective understanding?
- A. Atrial fibrillation may cause venous thromboembolism.
- B. Immediate defibrillation is needed for asystole.
- C. Cardioversion may be used for ventricular fibrillation.
- D. Adenosine is used to treat supraventricular tachycardia.
Correct Answer: D
Rationale: Adenosine is the first-line treatment for supraventricular tachycardia, rapidly slowing the heart rate.