Nokea
The physician orders continuous I.V. nitroglycerin infusion for the client with myocardial infarction. Essential nursing actions include which of the following?
- A. Obtaining an infusion pump for the medication.
- B. Monitoring blood pressure every 4 hours.
- C. Monitoring urine output hourly.
- D. Obtaining serum potassium levels daily.
Correct Answer: A
Rationale: An infusion pump ensures accurate delivery of nitroglycerin, which requires precise titration. BP monitoring should be more frequent (e.g., every 15-30 minutes), and urine output and potassium levels are not primary concerns.
You may also like to solve these questions
A client in hospice care is nearing death. Which of the following is an expected physical change the nurse should prepare the family for?
- A. Increased appetite.
- B. Cool, mottled extremities.
- C. Improved mental clarity.
- D. Regular breathing patterns.
Correct Answer: B
Rationale: Cool, mottled extremities are an expected sign of impending death due to decreased circulation, and preparing the family helps reduce distress.
Captopril (Capoten), furosemide (Lasix), and metoprolol (Toprol XL) are ordered for a client with systolic heart failure. The client's blood pressure is 136/82 and the heart rate is 65. Prior to medication administration at 9 a.m., the nurse reviews the following lab tests (see chart). Which of the following should the nurse do first?
- A. Administer the medications.
- B. Call the physician.
- C. Withhold the captopril.
- D. Question the metoprolol dose.
Correct Answer: B
Rationale: The potassium level of 6.8 mEq/L indicates hyperkalemia, a risk with captopril (an ACE inhibitor). Calling the physician is the priority to address this critical lab value.
A client with a recent amputation reports phantom limb pain. Which intervention should the nurse implement first?
- A. Administer prescribed gabapentin.
- B. Apply a cold pack to the stump.
- C. Distract the client with music.
- D. Explain the nature of phantom pain.
Correct Answer: D
Rationale: Explaining phantom pain validates the client's experience, addressing anxiety before other interventions.
Which assessment is critical for a client receiving thrombolytic therapy?
- A. Blood glucose.
- B. Blood pressure.
- C. Temperature.
- D. Cholesterol level.
Correct Answer: B
Rationale: Blood pressure is critical to monitor during thrombolytic therapy to prevent hemorrhagic complications.
The nurse is teaching the client about deep-breathing techniques. Which of the following client statements indicates the need for additional education?
- A. œI will use my incentive spirometer every hour while I'm awake.'
- B. œI should place my hands lightly over my lower ribs and upper abdomen.'
- C. œI should get into a comfortable position before doing my breathing exercises.'
- D. œI should take four deep breaths and then cough deeply from the lungs.'
Correct Answer: D
Rationale: Taking four deep breaths before coughing is incorrect, as the client should perform deep breaths and cough in a sequence, typically 2-3 breaths followed by a cough, to prevent atelectasis effectively.