Nokea
Which of the following nursing interventions should a nurse perform when caring for a client with congestive heart failure who has decreased cardiac output?
- A. Encourage activities that engage the Valsalva maneuver.
- B. Encourage the client to perform exercises.
- C. Assess apical heart rate before administering digitalis.
- D. Offer small, frequent feedings.
Correct Answer: C
Rationale: Digitalis therapy requires careful monitoring of heart rate to prevent toxicity and worsening cardiac output.
You may also like to solve these questions
Which chronic respiratory condition is characterized by the narrowing and inflammation of the airways, leading to difficulty breathing?
- A. Asthma
- B. COPD
- C. Bronchitis
- D. Pneumonia
Correct Answer: A
Rationale: Step-by-step rationale:
1. Asthma is characterized by airway inflammation and narrowing, leading to difficulty breathing.
2. It is a chronic respiratory condition with symptoms like wheezing, coughing, and shortness of breath.
3. Asthma exacerbations can be triggered by various factors like allergens or exercise.
4. Treatment includes bronchodilators and anti-inflammatory medications to manage symptoms.
5. COPD, bronchitis, and pneumonia involve different pathophysiological mechanisms and are not primarily characterized by airway narrowing.
Summary:
Asthma is the correct answer due to its specific features of airway inflammation and narrowing, distinct from COPD, bronchitis, and pneumonia, which have different underlying causes and symptoms.
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.
The client is receiving digoxin and has a potassium level of 2.8 mEq/L. What is the nurse's priority action?
- A. Hold the digoxin and notify the healthcare provider.
- B. Increase the dose of digoxin.
- C. Continue the current dose of digoxin.
- D. Administer potassium supplements.
Correct Answer: A
Rationale: The correct answer is A: Hold the digoxin and notify the healthcare provider. Digoxin toxicity is more likely to occur in patients with low potassium levels. With a potassium level of 2.8 mEq/L, the client is at risk for digoxin toxicity. Holding the digoxin and notifying the healthcare provider is the priority action to prevent potential harm to the client.
B: Increasing the dose of digoxin would exacerbate the risk of digoxin toxicity in a client with low potassium levels.
C: Continuing the current dose of digoxin without addressing the low potassium level could lead to digoxin toxicity.
D: Administering potassium supplements alone may not be sufficient to address the potential digoxin toxicity. Holding the digoxin is the priority action.
If Mr. Lane, with essential hypertension, complains of dizziness when changing position, your evaluation would be that Mr. Lane
- A. is probably not taking his medications properly
- B. should be instructed in preventing hypotensive reactions
- C. is responding as expected to the prescribed medications
- D. should be totally reevaluated
Correct Answer: B
Rationale: Dizziness may indicate postural hypotension, requiring preventive education.
What procedure is used to remove fluid from the pleural space to help a patient breathe more easily?
- A. Thoracentesis
- B. Bronchoscopy
- C. Echocardiogram
- D. CT scan
Correct Answer: A
Rationale: The correct answer is A: Thoracentesis. This procedure involves inserting a needle or catheter into the pleural space to drain excess fluid, relieving pressure and allowing the patient to breathe more easily. Bronchoscopy (B) is used to visualize the airways, not remove fluid. Echocardiogram (C) is an ultrasound of the heart, not used for pleural fluid drainage. CT scan (D) is an imaging test, not a procedure for fluid removal. Thoracentesis is the appropriate choice for this scenario.