Nokea
Which of the following should be monitored for patients taking diuretics? (select all that apply)
- A. Daily weight
- B. Intake and output
- C. Amount and location of edema
- D. Appetite
Correct Answer: A
Rationale: A. Daily weight should be monitored for patients taking diuretics because diuretics can cause fluid loss which may lead to weight changes. Fluctuations in weight can indicate changes in fluid balance and help determine the effectiveness of the diuretic therapy.
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Reye's syndrome, a potentially fatal illness associated with liver failure and encephalopathy is associated with the administration of which over-the-counter (OTC) medication?
- A. acetaminophen (Tylenol)
- B. ibuprofen (Motrin)
- C. aspirin
- D. brompheniramine/pseudoephedrine (Dimetapp)
Correct Answer: C
Rationale: Reye's syndrome is linked to the use of aspirin in children and adolescents, particularly during viral infections. It causes severe liver and brain damage. Acetaminophen, ibuprofen, and antihistamines are not associated with this condition. Avoiding aspirin in pediatric patients is critical to prevent this rare but life-threatening syndrome.
A patient in the outpatient oncology clinic complains of fatigue after receiving chemotherapy. Which initial nursing intervention will be most appropriate?
- A. Assess for other factors contributing to her fatigue, such as trouble sleeping.
- B. Encourage a high-protein, high-calorie diet, and design it with the patient.
- C. Refer the patient to a physical therapist to develop a strenuous exercise program.
- D. Encourage the patient to sleep as much as possible during the day to ease fatigue.
Correct Answer: A
Rationale: Fatigue is a common side effect of chemotherapy and can be caused by various factors, including anemia, poor nutrition, sleep disturbances, or psychological stress. The nurse's first step should be to assess for underlying causes of fatigue, such as trouble sleeping, anemia, or depression. Once the cause is identified, appropriate interventions can be implemented, such as dietary changes, sleep hygiene strategies, or treatment for anemia. Encouraging excessive daytime sleep or strenuous exercise without assessment may worsen fatigue or lead to other complications.
What is the common side effect that is normal with the initial therapy of Nitroglycerine due to increased vasodilation?
- A. Abdominal cramps
- B. Calf
- C. Headache
- D. Blurred vision
Correct Answer: C
Rationale: The most common side effect that is normal with the initial therapy of Nitroglycerine due to increased vasodilation is a headache. Nitroglycerine causes vasodilation of blood vessels, including the blood vessels in the head and brain. This can lead to headaches as a result of the increased blood flow and changes in blood vessel diameter. Headaches caused by Nitroglycerine are usually mild and transient. It is important to monitor patients for this expected side effect and educate them about it to ensure compliance with the medication regimen.
Which nursing diagnosis is appropriate for a patient receiving antidysrhythmics?
- A. Risk for infection
- B. Deficient knowledge
- C. Deficient fluid volume
- D. Urinary retention
Correct Answer: C
Rationale: The appropriate nursing diagnosis for a patient receiving antidysrhythmics would be Deficient fluid volume. Antidysrhythmics can have side effects such as electrolyte imbalances, which can lead to fluid volume deficit. Monitoring the patient's fluid intake and output is crucial to prevent dehydration and maintain proper electrolyte balance. Therefore, identifying Deficient fluid volume as a nursing diagnosis allows for appropriate interventions to be implemented to address and prevent this potential complication.
A patient with a history of HF presents to the emergency department with difficulty breathing, cough, and edema of the lower extremities. The nurse anticipates administration of which type of medication?
- A. Positive chronotrope
- B. Negative chronotrope
- C. Positive inotrope
- D. Negative inotrope
Correct Answer: C
Rationale: In the scenario described, the patient with a history of heart failure (HF) is presenting with symptoms of difficulty breathing, cough, and edema of the lower extremities. These signs and symptoms suggest acute decompensated heart failure (ADHF), which is characterized by a decrease in cardiac output and inadequate tissue perfusion. In this situation, the nurse would anticipate the administration of a positive inotrope medication.