The nurse has reviewed the Nurses' Notes, Diagnostic Results, and Laboratory Results.
Enoxaparin 80 mg subcutaneous twice a
Potassium chloride 20 mEq PO twice a day
Ciprofloxacin 750 mg PO twice a day
Enalapril 5 mg PO daily
Rosuvastatin 20 mg PO daily
Digoxin 0.25 mg PO daily
Metformin 850 mg PO daily
Albuterol 2 puffs every 4 to 6 hr as needed
Correct Answer : B,D,E,G
Rationale:
A. Enoxaparin 80 mg subcutaneous twice a day: Enoxaparin is an anticoagulant used for prevention or treatment of thromboembolic events. There is no indication from the client’s current labs, vitals, or diagnostics (D-dimer within normal limits, no evidence of clot) to initiate anticoagulation at this time.
B. Potassium chloride 20 mEq PO twice a day: The client’s potassium level is 3.6 mEq/L, which is at the lower end of the normal range. Supplementation may be warranted, particularly if antihypertensive therapy such as a diuretic is initiated, to prevent hypokalemia and maintain cardiac stability.
C. Ciprofloxacin 750 mg PO twice a day: There is no evidence of bacterial infection in the client’s assessment, labs, or diagnostics. Prescribing an antibiotic is unnecessary and not indicated.
D. Enalapril 5 mg PO daily: The client’s blood pressure is 164/92 mm Hg, which is hypertensive. Enalapril, an ACE inhibitor, is appropriate to manage hypertension, reduce cardiovascular risk, and potentially improve renal outcomes given the family history of renal failure.
E. Rosuvastatin 20 mg PO daily: The client has significantly elevated cholesterol (total cholesterol 280 mg/dL, LDL 220 mg/dL, HDL 20 mg/dL) and triglycerides 220 mg/dL. Initiating a statin is appropriate to reduce cardiovascular risk and manage hyperlipidemia.
F. Digoxin 0.25 mg PO daily: The client does not exhibit heart failure symptoms or arrhythmias that require digoxin at this time. ECG shows only sinus tachycardia without S-T changes, so digoxin is not indicated.
G. Metformin 850 mg PO daily: The client’s glucose is 310 mg/dL and HbA1c is 7%, indicating diabetes mellitus. Initiating metformin is appropriate for glycemic control and to reduce the risk of complications associated with hyperglycemia.
H. Albuterol 2 puffs every 4 to 6 hr as needed: The client’s lungs are clear on auscultation, and there is no active respiratory distress. Albuterol is not indicated for ongoing therapy in this assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. "Plan to take this medication with food.": Taking phenytoin with food can help reduce gastrointestinal irritation, such as nausea and upset stomach, which is a common side effect. Consistent administration with meals improves tolerability while maintaining therapeutic drug levels.
B. "Limit foods that contain folic acid while taking this medication.": Phenytoin can actually decrease folic acid absorption, and limiting folic acid intake could worsen potential deficiencies. Instead, monitoring and possibly supplementing folic acid may be recommended. Advising restriction could be harmful.
C. "Limit foods that contain vitamin D while taking this medication.": Phenytoin can reduce vitamin D metabolism, which may increase the risk of bone loss and fractures. Limiting vitamin D intake is not advised; rather, ensuring adequate vitamin D and calcium intake is important for older adults to maintain bone health.
D. "Plan to take this medication with antacids.": Antacids can interfere with the absorption of phenytoin, reducing its effectiveness. Taking phenytoin with antacids is contraindicated, and spacing the timing between antacids and phenytoin is necessary to maintain therapeutic levels.
Correct Answer is C
Explanation
Rationale:
A. Remove the client's catheter: Removing the catheter could allow more air to enter the circulation and worsen the embolism. The priority is to prevent further air entry while stabilizing the client, not immediate removal of the line.
B. Prepare the client for chest tube insertion: Chest tubes are used for pneumothorax or pleural effusions, not for treating an air embolism. Immediate positioning and oxygen therapy are the primary interventions.
C. Place the client in a left-lateral Trendelenburg position: Positioning the client in the left-lateral Trendelenburg (head down, left side down) traps air in the right atrium and prevents it from entering the pulmonary circulation, reducing cardiovascular compromise. This is the recommended first intervention for a suspected air embolism.
D. Instruct the client to perform the Valsalva maneuver: Performing the Valsalva maneuver increases intrathoracic pressure and may temporarily help, but it is not the first priority. Proper positioning and immediate oxygen administration are more critical to prevent complications.
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