A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification?
Laboratory testing of serum potassium upon admission
Bumetanide 1 mg IV bolus every 12 hr
0.9% normal saline IV at 50 mL/hr continuous
Morphine sulfate 2 mg IV bolus every 2 hr PRN pain
The Correct Answer is C
Choice A Reason: This choice is incorrect because laboratory testing of serum potassium upon admission is an appropriate prescription for a client who has acute heart failure following MI. Serum potassium is an electrolyte that affects the cardiac function and rhythm. A normal serum potassium range is 3.5 to 5 mEq/L, and an abnormal level can indicate hypokalemia or hyperkalemia, which can cause arrhythmias, muscle weakness, or paralysis. Therefore, monitoring serum potassium is important to detect and correct any electrolyte imbalance and prevent complications.
Choice B Reason: This choice is incorrect because bumetanide 1 mg IV bolus every 12 hr is an appropriate prescription for a client who has acute heart failure following MI. Bumetanide is a loop diuretic that helps to reduce fluid retention and edema by increasing the urine output and sodium excretion. It may be used for clients who have heart failure, hypertension, or renal impairment, but it can cause hypokalemia, hypotension, or dehydration.
Therefore, administering bumetanide as prescribed can help to improve the cardiac output and reduce the preload and afterload.
Choice C Reason: This choice is correct because 0.9% normal saline IV at 50 mL/hr continuous is an inappropriate prescription for a client who has acute heart failure following MI. 0.9% normal saline is an isotonic solution that contains the same concentration of solutes as blood plasma. It may be used for clients who have fluid loss, dehydration, or shock, but it can worsen fluid overload and pulmonary edema in clients who have acute heart failure. Therefore, clarifying this prescription with the provider is necessary to prevent further deterioration of the client's condition.
Choice D Reason: This choice is incorrect because morphine sulfate 2 mg IV bolus every 2 hr PRN pain is an appropriate prescription for a client who has acute heart failure following MI. Morphine sulfate is an opioid analgesic that helps to relieve pain and anxiety by binding to the opioid receptors in the brain and spinal cord. It may be used for clients who have moderate to severe pain, dyspnea, or chest discomfort, but it can cause respiratory depression, hypotension, or nausea. Therefore, administering morphine sulfate as prescribed can help to reduce the oxygen demand and improve the cardiac function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This choice is incorrect because it reflects the nurse's feelings rather than focusing on the client's needs. Saying "That's a hurtful thing to say" may make the client feel guilty or defensive, and it does not address the underlying cause of the client's anger or frustration.
Choice B Reason: This choice is incorrect because it sounds accusatory and confrontational rather than empathetic and supportive. Asking "Why would you say such a thing?" may make the client feel judged or criticized, and it does not explore the client's feelings or concerns.
Choice C Reason: This choice is incorrect because it dismisses the client's feelings rather than acknowledging them. Saying "Well, that's your opinion" may make the client feel ignored or invalidated, and it does not show respect or compassion for the client.
Choice D Reason: This choice is correct because it invites the client to express their feelings and concerns rather than shutting them down. Saying "Tell me more about that" may make the client feel heard and understood, and it may help to identify the source of their anger or frustration. The nurse can then use therapeutic communication skills such as active listening, reflecting, clarifying, or validating to establish rapport and trust with the client.
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because a thrombotic stroke is caused by a clot that forms in a cerebral artery, usually due to atherosclerosis. It typically occurs gradually and does not cause a sudden, severe headache or seizure.
Choice B Reason: This is incorrect because an embolic stroke is caused by a clot that travels from another part of the body, such as the heart, to a cerebral artery. It usually occurs abruptly and does not cause vomiting or fever.
Choice C Reason: This is incorrect because a transient ischemic atack (TIA) is caused by a temporary interruption of blood flow to a part of the brain. It usually lasts less than an hour and does not cause permanent brain damage or loss of consciousness.
Choice D Reason: This is correct because a hemorrhagic stroke is caused by a rupture of a blood vessel in the brain, resulting in bleeding into the brain tissue or the subarachnoid space. It usually causes a sudden, severe headache, vomiting, seizure, and loss of consciousness. It can also cause elevated blood pressure, fever, and increased intracranial pressure.
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