An elderly client with heart failure comet to the emergency room because of nausea, vomiting, and anorexia. Based on the client’s signs and symptoms, which data from the medical history has the most significance when planning this client’s care?

A coronary artery bypass procedure was performed in 1995.

Suﬀered with depression following death of spouse in 1999.

Digoxin and furosemide daily since 1996.

A Colonoscopy was performed for routine screening six months ago.

Answer and Explanation

The Correct Answer is C

Digoxin is a medication commonly used to treat heart failure by strengthening the heart's contractions and slowing down the heart rate. However, it can also cause nausea, vomiting, and loss of appetite, especially when levels in the body are too high. Furosemide is a diuretic medication that helps to remove excess ﬂuid from the body, which is often necessary in heart failure. However, it can also cause electrolyte imbalances, such as low potassium levels, which can contribute to nausea and vomiting.

Therefore, in a client with heart failure who is experiencing these symptoms, it is important to assess their medication regimen, including dosages and serum levels, to ensure that they are not experiencing medication side eﬀects or toxicity.

Adjustments may need to be made to the client's medication regimen to manage symptoms eﬀectively and prevent further complications. Options (a), (b), and (d) do not have as direct a correlation to the current symptoms and would not have the same level of significance when planning care for this client.

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Correct Answer is B

Explanation

Cyclosporine is an immunosuppressive medication commonly used to prevent graft rejection after organ transplantation. St. John's Wort is known to induce cytochrome P450 enzymes, which can increase the metabolism and decrease the eﬀectiveness of many medications, including cyclosporine. This interaction can lead to decreased plasma concentrations of cyclosporine, which can increase the risk of graft rejection. Therefore, it is important to advise the client to discontinue the use of St. John's Wort and inform their healthcare provider about any herbal or supplement use to prevent potential interactions with prescribed medications. Options a, c, and d are not directly related to the client's current condition and are not as significant as option b.

A. Assess urine output. B. Perform a bladder scan. C. Monitor blood pressure. D. Obtain daily weights.

Correct Answer is C

Explanation

Tamsulosin is an alpha-1 adrenergic receptor blocker that is commonly used to treat benign prostatic hyperplasia (BPH). One of the potential adverse reactions of tamsulosin is hypotension, which can be manifested as dizziness, lightheadedness, and fainting. Therefore, monitoring blood pressure is a crucial intervention for clients receiving tamsulosin.

Assessing urine output (option a) and performing a bladder scan (option b) may be appropriate interventions for clients with urinary retention or other urinary tract issues, but they are not specific to monitoring adverse reactions to tamsulosin.

Obtaining daily weights (option d) may be useful for monitoring ﬂuid balance in some clients, but it is not directly related to adverse reactions to tamsulosin.

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An elderly client with heart failure comet to the emergency room because of nausea, vomiting, and anorexia. Based on the client’s signs and symptoms, which data from the medical history has the most significance when planning this client’s care?

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Correct Answer is B

Explanation

A client with benign prostatic receives a new prescription of tamsulosin. Which intervention should the nurse use to monitor an adverse reaction?

Correct Answer is C

Explanation

An elderly client with heart failure comet to the emergency room because of nausea, vomiting, and anorexia. Based on the client’s signs and symptoms, which data from the medical history has the most significance when planning this client’s care?

Before administering a newly prescribed dose of terbinafine HCL to a client with a fungal toenail infection, which assessment finding is most important for the nurse to address?

A client receives a new prescription for levothyroxine. Which statement made by client indicates to the nurse that the education was eﬀective?

A client with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in this patient’s plan of care?

A client with hepatic encephalopathy is receiving lactulose. Which assessment provides the nurse with the nest information to evaluate the client’s therapeutic response to the drug?

A client who receives multiple antihypertensive multiple medications experiences syncope due to a drop in blood pressure to 70/40 mm Hg. Which is the rationale for the nurse’s decision to hold the client’s scheduled antihypertensive medications?

The home health nurse observes a client self-administering an epinephrine injection using an auto-injector pen. Which client action requires intervention by the nurse?

A client with open-angle glaucoma asks the nurse how long the prescribed eye drops will need to be used. Which response made by the nurse is accurate?