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When administering enoxaparin (Lovenox) to a client, what is the most important lab value to monitor?
- A. Platelet count
- B. aPTT
- C. Hemoglobin
- D. INR
Correct Answer: A
Rationale: The correct answer is A: Platelet count. When administering enoxaparin, the most important lab value to monitor is the platelet count because enoxaparin can cause thrombocytopenia, a potentially serious adverse effect. Monitoring platelet count helps to detect and prevent this complication.
Summary of other choices:
B: aPTT - Enoxaparin does not directly affect aPTT, so monitoring this value is not as critical as platelet count.
C: Hemoglobin - While monitoring hemoglobin may be important for some conditions, it is not the most crucial lab value to monitor when administering enoxaparin.
D: INR - Enoxaparin does not affect the INR, so monitoring this value is not necessary when administering this medication.
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A client on spironolactone (Aldactone) has a potassium level of 6.0 mEq/L. What is the nurse's priority action?
- A. Hold the spironolactone and notify the healthcare provider.
- B. Administer a potassium supplement.
- C. Continue the spironolactone as ordered.
- D. Increase the dose of spironolactone.
Correct Answer: A
Rationale: The correct answer is A: Hold the spironolactone and notify the healthcare provider. Spironolactone is a potassium-sparing diuretic that can lead to hyperkalemia. With a potassium level of 6.0 mEq/L, the client is at risk for serious cardiac complications. Holding the medication and notifying the healthcare provider is the priority to prevent further increase in potassium levels. Administering a potassium supplement (B) would exacerbate the hyperkalemia. Continuing the spironolactone as ordered (C) or increasing the dose (D) would also worsen the situation.
Which condition is characterized by fluid collection in the lungs, making it difficult to breathe?
- A. Pulmonary edema
- B. Pleurisy
- C. Pleural effusion
- D. Pneumothorax
Correct Answer: A
Rationale: Pulmonary edema is the correct answer because it is characterized by fluid accumulation in the lungs, leading to difficulty in breathing. This condition is often a result of heart failure, where the heart is unable to pump blood effectively, causing fluid to leak into the lungs. It can also be caused by lung infections or exposure to toxins.
Pleurisy (B) is inflammation of the pleura, the lining around the lungs, leading to chest pain exacerbated by breathing. Pleural effusion (C) is fluid accumulation in the pleural space around the lungs, not within the lungs themselves. Pneumothorax (D) is characterized by air accumulation in the pleural space, causing lung collapse, but not fluid collection in the lungs.
When administering furosemide (Lasix) to a client, which lab value is most important to monitor?
- A. Potassium
- B. Sodium
- C. Calcium
- D. Chloride
Correct Answer: A
Rationale: The correct answer is A: Potassium. Furosemide is a loop diuretic that can cause potassium loss through increased urine output. Monitoring potassium levels is crucial to prevent hypokalemia, which can lead to serious cardiac arrhythmias. Sodium (B) and chloride (D) levels can also be affected by furosemide but are not as critical as potassium. Calcium (C) monitoring is not typically required when administering furosemide. By closely monitoring potassium levels, healthcare providers can prevent potential complications and ensure the safe administration of furosemide.
Which of the following conditions is characterized by inflammation of the heart muscle, often due to a viral infection, leading to impaired heart function?
- A. Myocarditis
- B. Endocarditis
- C. Pericarditis
- D. Cardiomyopathy
Correct Answer: A
Rationale: Myocarditis is the correct answer because it specifically refers to inflammation of the heart muscle often caused by a viral infection, leading to impaired heart function. It directly addresses the condition described in the question. Endocarditis is inflammation of the inner lining of the heart chambers and valves, not the heart muscle. Pericarditis is inflammation of the outer lining of the heart, not the heart muscle. Cardiomyopathy is a general term for diseases of the heart muscle that impair its ability to pump blood, but it does not specifically mention inflammation caused by viral infections.
The nurse is caring for a client on digoxin with a heart rate of 48 bpm. What is the nurse's priority action?
- A. Hold the digoxin and notify the healthcare provider.
- B. Administer the digoxin as ordered.
- C. Administer atropine to increase the heart rate.
- D. Increase the dose of digoxin.
Correct Answer: A
Rationale: The correct answer is A: Hold the digoxin and notify the healthcare provider. A heart rate of 48 bpm is below the normal range, indicating bradycardia, a potential side effect of digoxin toxicity. Holding the medication and informing the healthcare provider is crucial to prevent further harm. Administering the digoxin (B) can worsen the bradycardia. Atropine (C) is not the first-line treatment for digoxin-induced bradycardia. Increasing the dose of digoxin (D) can exacerbate toxicity. Overall, prompt action to address the underlying cause is essential in this situation.