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The primary health care provider prescribes a dose of intravenous (IV) potassium chloride for a client. When administering the IV potassium chloride, which action should the nurse take?
- A. Inject it as a bolus.
- B. Use a filter in the IV line.
- C. Dilute it per medication instructions.
- D. Apply cool compresses to the IV site.
Correct Answer: C
Rationale: Potassium chloride is very irritating to the vein and must be diluted to prevent phlebitis and is administered using an IV pump. Potassium chloride is never administered as a bolus injection because it can cause cardiac arrest. A filter is not necessary for potassium solutions. Cool compresses would constrict the blood vessel, which could possibly be more irritating to the vein.
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As the nurse begins to administer scheduled doses of furosemide and nifedipine, the client asks for a PRN dose of aluminum hydroxide. Which action by the nurse would be best ensure the effectiveness of all the medications?
- A. Assess the client's immediate need for the antacid.
- B. Administer all three medications at the same time.
- C. Administer the nifedipine and aluminum hydroxide, then the furosemide 1 hour later.
- D. Administer the furosemide and aluminum hydroxide, then the nifedipine 1 hour later.
Correct Answer: A
Rationale: Antacids such as aluminum hydroxide often interfere with the absorption of other medications. For this reason, antacids should be separated from other medications by at least 1 hour. Because of the diuretic action of the furosemide and the antihypertensive action of the nifedipine, it is important to administer them on time if the client can tolerate waiting for the aluminum hydroxide. The nurse should assess the client to determine the need for the antacid.
The nurse is assessing a client diagnosed with cardiac disease at the 30 weeks' gestation antenatal visit. The nurse assesses lung sounds in the lower lobes after a routine blood pressure screening. The nurse performs this assessment to elicit what information?
- A. Identify mitral valve prolapse.
- B. Identify cardiac dysrhythmias.
- C. Rule out the possibility of pneumonia.
- D. Assess for early signs of heart failure (HF).
Correct Answer: D
Rationale: Fluid volume during pregnancy peaks between 18 and 32 weeks' gestation. During this period, it is essential to observe and record maternal data that would indicate further signs of cardiac decompensation or HF in the pregnant client with cardiac disease. By assessing lung sounds, the nurse may identify early symptoms of diminished oxygen exchange and potential HF. Options 1, 2, and 3 are not related to the data in the question.
The nurse suspecting that a client is developing cardiogenic shock should assess for which peripheral vascular manifestation of this complication? Select all that apply.
- A. Warm, moist skin
- B. Flushed, dry skin
- C. Cool, clammy skin
- D. Irregular pedal pulses
- E. Bounding pedal pulses
- F. Weak or thready pedal pulses
Correct Answer: C,F
Rationale: Some of the manifestations of cardiogenic shock include increased pulse (weak and thready); decreased blood pressure; decreasing urinary output; signs of cerebral ischemia (confusion, agitation); and cool, clammy skin. None of the remaining options are associated with the peripheral vascular aspects of cardiogenic shock.
The nurse is caring for a client diagnosed with preeclampsia. When the client's condition progresses from preeclampsia to eclampsia, what should the nurse's first action be?
- A. Maintain an open airway.
- B. Administer oxygen by face mask.
- C. Assess the maternal blood pressure and fetal heart tones.
- D. Administer an intravenous infusion of magnesium sulfate.
Correct Answer: A
Rationale: Eclampsia is characterized by the occurrence of seizures. If the client experiences seizures, it is important as a first action to establish and maintain an open airway and prevent injuries to the client. Options 2, 3, and 4 are all interventions that should be done but not initially.
During history taking of a client admitted with newly diagnosed Hodgkin's disease, which symptom should the nurse expect the client to report?
- A. Weight gain
- B. Night sweats
- C. Severe lymph node pain
- D. Headache with minor visual changes
Correct Answer: B
Rationale: Assessment of a client with Hodgkin's disease most often reveals night sweats; enlarged, painless lymph nodes; fever; and malaise. Weight loss may be present if metastatic disease occurs. Headache and visual changes may occur if brain metastasis is present.