Nokea
You are working with an experienced nursing assistant and LPN/LVN in caring for a group of patients. You have developed a nursing diagnosis of Activity Intolerance related to fatigue and chest pain for a patient who had an acute myocardial infarction 3 days ago. Which of these nursing activities included in the care plan is best delegated to the LPN/LVN?
- A. Administer nitroglycerin (Nitro-Stat) if chest discomfort occurs during patient activities.
- B. Monitor pulse, blood pressure, and oxygen saturation before and after patient ambulation.
- C. Teach the patient energy conservation techniques to decrease myocardial oxygen demand.
- D. Explain the rationale for alternating rest periods with exercise to the patient and family.
Correct Answer: B
Rationale: Monitoring vital signs is within the scope of practice for an LPN/LVN and does not require advanced assessment skills.
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The client is on amiodarone. What is the most important side effect to monitor for?
- A. Pulmonary toxicity
- B. Thyroid dysfunction
- C. Liver toxicity
- D. Renal dysfunction
Correct Answer: A
Rationale: The correct answer is A: Pulmonary toxicity. Amiodarone is known to cause potentially fatal pulmonary toxicity, including interstitial pneumonitis and pulmonary fibrosis. Monitoring for pulmonary symptoms such as cough, dyspnea, and chest pain is crucial. Choice B (Thyroid dysfunction) is a common side effect but is typically less urgent. Choices C (Liver toxicity) and D (Renal dysfunction) are possible side effects of amiodarone, but pulmonary toxicity is the most important to monitor due to its severity and potential fatality.
High SVR is most likely to cause damage to which organ?
- A. Brain
- B. Heart
- C. Retina
- D. Kidney
Correct Answer: D
Rationale: Elevated SVR strains renal arterioles, leading to kidney damage.
When administering enoxaparin (Lovenox) to a client for DVT prophylaxis, what is the most important lab value to monitor?
- A. Platelet count
- B. PT/INR
- C. aPTT
- D. Hemoglobin
Correct Answer: A
Rationale: The correct answer is A: Platelet count. When administering enoxaparin for DVT prophylaxis, monitoring platelet count is crucial because enoxaparin can cause thrombocytopenia. Decreased platelet count can increase the risk of bleeding. Monitoring PT/INR and aPTT is more relevant for monitoring warfarin or heparin therapy, not enoxaparin. Hemoglobin monitoring is important for assessing anemia but not specifically related to enoxaparin administration for DVT prophylaxis.
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.
The client on furosemide (Lasix) is at risk for which electrolyte imbalance?
- A. Hyperkalemia
- B. Hypokalemia
- C. Hyponatremia
- D. Hypernatremia
Correct Answer: B
Rationale: The correct answer is B, Hypokalemia. Furosemide is a loop diuretic that increases potassium excretion in the urine, leading to low potassium levels in the body. Hypokalemia can result in muscle weakness, cardiac arrhythmias, and other serious complications. Hyperkalemia (choice A) is the opposite condition of high potassium levels and is not typically associated with furosemide use. Hyponatremia (choice C) is a low sodium level, which may be a potential side effect of furosemide but is not the primary electrolyte imbalance to be concerned about. Hypernatremia (choice D) is high sodium levels and is not directly related to furosemide use.