A nurse is admitting a client to the medical-surgical unit.
Based on the nurse's assessment findings, click to highlight the specific interventions and orders the nurse would expect to implement for this client.
- Administer furosemide 40 mg via IV push once.
- Begin an IV infusion of normal saline (NS) at 150 mL/hr.
- Administer digoxin 0.25 mg via IV push NOW.
- Monitor daily weights.
- Call a code STEMI.
- Monitor strict intake and output.
- Prepare the client for an echocardiogram.
- Prepare the client for a radiofrequency catheter ablation.
Administer furosemide 40 mg via IV push once.
Begin an IV infusion of normal saline (NS) at 150 mL/hr.
Administer digoxin 0.25 mg via IV push NOW.
Monitor daily weights.
Call a code STEMI.
Monitor strict intake and output.
Prepare the client for an echocardiogram.
Prepare the client for a radiofrequency catheter ablation.
The Correct Answer is ["A","D","F","G"]
A. Administering furosemide 40 mg via IV push once is appropriate for treating fluid overload, as evidenced by pitting edema and crackles in the lungs, common in heart failure.
B. An IV infusion of normal saline (NS) at 150 mL/hr is not appropriate for this client as it can exacerbate fluid overload and worsen heart failure symptoms.
C. Administering digoxin 0.25 mg via IV push NOW may be indicated, but considering the client's low pulse rate (55/min), caution is necessary due to the risk of digoxin toxicity and bradycardia.
D. Monitoring daily weights is crucial for assessing fluid balance in heart failure patients and detecting any changes in fluid status.
E. Calling a code STEMI is not appropriate as the client does not exhibit signs of a STEMI; troponin levels are not elevated, and there is no indication of an acute myocardial infarction.
F. Monitoring strict intake and output helps in managing fluid balance and ensuring accurate assessment of the client's fluid status.
G. Preparing the client for an echocardiogram is appropriate to assess cardiac function and evaluate the severity of heart failure.
H. Radiofrequency catheter ablation is not indicated for this client as it is typically used to treat arrhythmias, not heart failure or fluid overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This statement indicates a lack of understanding about hidden sodium in restaurant foods. Many restaurant dishes contain high levels of sodium, even if additional salt is not added at the table. The client needs to be educated about choosing low-sodium options when dining out and asking about the sodium content of meals.
B. This statement reflects correct understanding, as fresh vegetables typically contain less sodium than canned vegetables, which often have added salt.
C. This statement shows proper knowledge, as reading nutrition labels helps identify foods with high sodium content, allowing for better dietary choices.
D. This statement is appropriate, as using lemon juice and herbs is a good alternative to adding salt for flavoring food.
Correct Answer is C
Explanation
A. Atrial fibrillation is characterized by an irregularly irregular rhythm and absence of distinct P-waves.
B. Atrial flutter typically presents with "saw-tooth" flutter waves rather than extra P-waves.
C. Premature atrial contractions (PACs) are identified by the presence of extra P-waves on an ECG.
D. Stable angina is related to chest pain and does not have specific ECG findings such as extra P-waves.
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