Nokea
Which intervention should the nurse prioritize for a client with ventricular tachycardia?
- A. Administer lidocaine as prescribed.
- B. Check blood pressure.
- C. Encourage deep breathing.
- D. Apply oxygen at 2 L/min.
Correct Answer: A
Rationale: Lidocaine is used to suppress ventricular tachycardia, a life-threatening arrhythmia.
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Which assessment finding would indicate to the nurse that the client is experiencing an arterial disorder?
- A. Leg pain that worsens with exercise
- B. Swelling in the ankles at the end of the day
- C. Dark, crusty skin on the lower legs
- D. Numbness in the feet when lying down
Correct Answer: A
Rationale: Arterial disorders, such as peripheral artery disease, often cause claudication, which is leg pain that worsens with exercise due to inadequate blood flow.
The client with pericarditis is prescribed ibuprofen. What is the primary purpose of this medication?
- A. Reduce fever
- B. Relieve inflammation
- C. Prevent blood clots
- D. Lower blood pressure
Correct Answer: B
Rationale: Ibuprofen reduces pericardial inflammation, alleviating pain and swelling.
The nurse is teaching the client diagnosed with deep vein thrombosis and prescribed warfarin. Which should the nurse teach the client? Select all that apply.
- A. Keep a constant amount of green, leafy vegetables in the diet.
- B. Instruct the client to have regular INR laboratory work done.
- C. Tell the client to go to the hospital immediately for any bleeding.
- D. Inform the client to notify the HCP if having dark, tarry stools.
- E. Encourage the client to avoid all green vegetables.
- F. Have the client take iron orally to prevent bleeding.
Correct Answer: A,B,D
Rationale: Constant green vegetable intake (A), regular INR (B), and reporting tarry stools (D) ensure safe warfarin use. Avoiding all greens (E) is unnecessary, and iron (C) doesn’t prevent bleeding. Immediate hospital for any bleeding (C) is excessive; minor bleeding requires HCP contact.
The client with restrictive cardiomyopathy asks why they feel short of breath. What is the best response?
- A. Your heart cannot fill properly.
- B. Your lungs are inflamed.
- C. Your blood pressure is too low.
- D. Your heart rate is too fast.
Correct Answer: A
Rationale: Restrictive cardiomyopathy impairs ventricular filling, reducing cardiac output and causing shortness of breath.
The client diagnosed with a DVT is on a heparin drip at 1,400 units per hour, and Coumadin (warfarin sodium, also an anticoagulant) 5 mg daily. Which intervention should the nurse implement first?
- A. Check the PTT and PT/INR.
- B. Check with the HCP to see which drug should be discontinued.
- C. Administer both medications.
- D. Discontinue the heparin because the client is receiving Coumadin.
Correct Answer: A
Rationale: Check PTT (heparin) and PT/INR (warfarin) (A) to assess therapeutic levels before action. HCP check (B), administering (C), or discontinuing (D) depend on lab results (heparin often continues briefly with warfarin).