An elderly client with heart failure arrives at the emergency room due to nausea, vomiting, and anorexia.
Based on the client’s signs and symptoms, which piece of data from the medical history is most significant when planning this client’s care?

The client underwent a coronary artery bypass procedure in 1995.

The client had a colonoscopy performed for routine screening six months ago.

The client suffered from depression following the death of their spouse in 1999.

The client has been taking digoxin and furosemide daily since 1996.

Answer and Explanation

The Correct Answer is D

Choice A rationale

While a coronary artery bypass procedure is a significant event in a patient’s medical history, it occurred in 1995, which is quite some time ago. Therefore, it may not be the most significant piece of data when planning this client’s care, given their current signs and symptoms.

Choice B rationale

A colonoscopy performed for routine screening six months ago is unlikely to be related to the client’s current symptoms of nausea, vomiting, and anorexia. Therefore, this choice is not the most significant piece of data when planning this client’s care.

Choice C rationale

Depression following the death of a spouse can significantly impact a person’s mental health. However, this event occurred in 1999, and while it may contribute to the client’s overall health status, it is not likely to be the most significant piece of data for planning care based on the client’s current symptoms.

Choice D rationale

The client has been taking digoxin and furosemide daily since 19962. Both of these medications are used to treat heart conditions. Digoxin strengthens the heart’s contractions, while furosemide is a diuretic that helps reduce fluid buildup. Given the client’s symptoms of nausea, vomiting, and anorexia, and their diagnosis of heart failure, this information is crucial. These symptoms could indicate a worsening of heart failure or side effects of the medication, which would significantly influence the plan of care.

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Correct Answer is ["42"]

Explanation

To calculate the infusion rate in gtt/min, we first need to calculate the infusion rate in mL/hr. The formula for this is:

Step 1: Calculate the infusion rate in mL/hr

Infusion rate (mL/hr)=Total time (hr)Total volume (mL) Substituting the given values: Infusion rate (mL/hr)=2 hr mL=250 mL/hr

Step 2: Convert the infusion rate from mL/hr to gtt/min Infusion rate (gtt/min)=60 min/hrInfusion rate (mL/hr)×Drop factor (gtt/mL).

Substituting the given values: Infusion rate (gtt/min)=60 min/hr mL/hr×10 gtt/mL ≈42 gtt/min Therefore, the nurse should regulate the infusion to approximately 42 gtt/min.

A. Instruct the patient to exhale rapidly into the mouthpiece when using the discus. B. Explain that the patient should not use the discus more than twice daily. C. Inform that patients using the discus may experience a decrease in blood pressure. D. Suggest offering the discus to the patient for use during an acute asthma attack.

Correct Answer is B

Explanation

Choice A rationale

Instructing the patient to exhale rapidly into the mouthpiece when using the discus is incorrect. The patient should breathe in through their mouth as deeply as they can until they have taken a full deep breath.

Choice B rationale

Fluticasone and salmeterol is a combination of two medicines that are used to help control the symptoms of asthma and improve breathing. It is used when a patient’s asthma has not been controlled sufficiently on other asthma medicines, or when a patient’s condition is so severe that more than one medicine is needed every day. Therefore, explaining that the patient should not use the discus more than twice daily is the correct instruction.

Choice C rationale

Informing that patients using the discus may experience a decrease in blood pressure is incorrect. The most common side effects of fluticasone and salmeterol include drowsiness, dizziness, and weakness.

Choice D rationale

Suggesting offering the discus to the patient for use during an acute asthma attack is incorrect. Fluticasone and salmeterol is not used to relieve an asthma attack that has already started.

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An elderly client with heart failure arrives at the emergency room due to nausea, vomiting, and anorexia.Based on the client’s signs and symptoms, which piece of data from the medical history is most significant when planning this client’s care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is receiving a secondary infusion of azithromycin 500 mg in 500 mL of normal saline (NS) to be infused over 2 hours. The intravenous (IV) administration set delivers 10 gtt/mL. How many gtt/min should the nurse regulate the infusion?

Correct Answer is ["42"]

Explanation

A patient in a residential treatment facility uses a fluticasone propionate and salmeterol discus inhalation system to manage asthma.This system delivers an inhaled powdered form of these combined medications. What instruction should the nurse provide to this patient’s caregivers?

Correct Answer is B

Explanation

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An elderly client with heart failure arrives at the emergency room due to nausea, vomiting, and anorexia.
Based on the client’s signs and symptoms, which piece of data from the medical history is most significant when planning this client’s care?