Nokea
The nurse reviews the client's continuous telemetry monitor and observes the following. As the nurse reviews the client's current medications, which prescribed medication is most likely causing this tracing? See the image below.
- A. losartan
- B. nitroglycerin transdermal patch
- C. enalapril
- D. verapamil
Correct Answer: D
Rationale: Verapamil, a calcium channel blocker, can cause bradycardia or heart block, potentially leading to abnormal ECG tracings.
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The nurse is caring for a client recovering from myocardial infarction who is presenting with a heart rate of 110 beats per minute, a blood pressure of 86/58 mmHg, crackles, shortness of breath, dusky skin, and jugular vein distention. Which action should the nurse recognize as the highest priority?
- A. Administer medications to increase stroke volume.
- B. Provide analgesics.
- C. Obtain a STAT electrocardiogram and troponins.
- D. Administer fluid replacement to increase blood pressure.
Correct Answer: D
Rationale: These findings suggest cardiogenic shock with pulmonary edema. Fluid replacement may be needed, but cautiously, to optimize preload.
Which of the following findings would the nurse expect to observe in a client with peripheral arterial disease (PAD)? Select all that apply.
- A. Decreased peripheral pulses
- B. Pain with ambulation
- C. Reddish-brown ankle discoloration
- D. Bilateral dependent edema
- E. Protruding veins in the leg
Correct Answer: A,B,C
Rationale: Decreased pulses result from arterial obstruction. Pain with ambulation (claudication) is a hallmark of PAD. C: Correct - Reddish-brown discoloration indicates chronic arterial insufficiency. D: Incorrect - Edema is more typical of venous issues. E: Incorrect - Protruding veins suggest venous disease, not arterial.
The nurse is assessing a client with clinical manifestations of right ventricular heart failure (HF). Which of the following statements by the client would be consistent with this diagnosis?
- A. I notice that my feet are always swollen.
- B. I can't seem to get rid of this wet cough.
- C. I develop shortness of breath after I walk a few feet.
- D. My legs start to burn if I walk long distances.
Correct Answer: A
Rationale: Right ventricular heart failure causes systemic venous congestion, leading to peripheral edema, such as swollen feet.
The following scenario applies to the next 1 items
The nurse in the outpatient clinic is caring for a 37-year-old male client
Item 1 of 1
Nurses' Note Physician Orders Current Medications
1100: The client reports intermittent dizziness that started following the dosage increase of his prescribed spironolactone one week ago. The client states that it is worse for a few hours after he takes the medication but then resolves. On assessment, the client is alert and oriented. The client's breathing is unlabored and has clear lung fields bilaterally. Skin warm to the touch and pink in tone; pulses 2+ and regular. Capillary refill is 3 seconds. He denies any pain.
Vital signs: T 98.6° F (37° C), P 76, RR 16, BP 130/86, pulse oximetry reading 98% on room air. Medical history of hypertension and hyperlipidemia.
The nurse prepares to obtain the client's orthostatic blood pressure (BP) by first positioning the client …………. then positioning the client …………. the client …………. When obtaining the blood pressure, the nurse should ……………….. The nurse should be concerned for orthostatic hypotension if the systolic blood pressure decreases by ………….. or the diastolic blood pressure decreases by……………….
- A. Standing
- B. Supine
- C. Sitting
- D. Obtain the blood pressure with the client's arm in the dependent position.
- E. Keep the blood pressure cuff in the same position.
- F. Obtain BP readings 10 minutes after the client changes position.
- G. 20 mm Hg
Correct Answer: B,C,A,E,G
Rationale: Orthostatic BP is measured supine (B), then sitting (C), then standing (A). The cuff should stay in the same position (E). A drop of 20 mm Hg systolic (G) or 10 mm Hg diastolic
Which of the following interventions should the nurse implement to manage fluid volume overload in a client with heart failure? Select all that apply.
- A. Administer diuretics as prescribed
- B. Monitor daily weights
- C. Restrict fluid intake to 500 mL per day
- D. Assess lung sounds for crackles
- E. Encourage high-sodium diet
- F. Assess lung sounds for rhonchi
Correct Answer: A,B,D
Rationale: Diuretics reduce fluid overload. Daily weights monitor fluid status. C: Incorrect - 500 mL/day is too restrictive; 1.5-2 L is typical. D: Correct - Crackles indicate pulmonary edema. E: Incorrect - High-sodium diets worsen fluid retention. F: Incorrect - Rhonchi are not specific to fluid overload.