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. Provide information about stress management.: Stress is a major trigger for vasospastic episodes in Raynaud’s disease because it increases sympathetic nervous system activity, causing further arterial constriction. Stress-reduction techniques such as deep breathing, biofeedback, or relaxation exercises helps reduce the frequency and severity of attacks.
B. Administer epinephrine for acute episodes.: Epinephrine causes vasoconstriction, which would worsen Raynaud’s symptoms by further reducing blood flow to the extremities. During an acute episode, warming the affected areas and avoiding additional vasoconstrictors is essential. Epinephrine is not indicated as a treatment and can intensify ischemic discomfort
C. Maintain a cool temperature in the client's room.: Cold temperatures are one of the most common triggers for vasospasm in Raynaud’s disease. A cool environment increase the likelihood of an episode by promoting peripheral vasoconstriction. The nurse should provide a warm environment and encourage protective clothing to maintain circulation.
D. Give a glucocorticoid steroid twice per day.: Steroids are not a standard treatment for Raynaud’s because the condition is related to vasospasm rather than inflammatory processes. Routine steroid use would expose the client to unnecessary adverse effects without addressing the underlying problem. Management strategies focus instead on warmth, lifestyle modification, and vasodilator medications when needed.
Correct Answer is A
Explanation
Rationale:
A. Required immunizations: Immunizations are a key aspect of primary prevention, as they protect children from preventable diseases before exposure occurs. Including information about required vaccines at the kindergarten level helps caregivers ensure children are protected and supports community health.
B. Nutrition for children who have diabetes: Nutrition management for children with diabetes is considered secondary or tertiary prevention, as it involves managing an existing condition rather than preventing disease onset. It is not the focus for primary prevention at a general health fair.
C. Emergency disaster planning: While disaster planning is important for safety, it is not classified as primary prevention of disease. It addresses preparedness rather than preventing the initial occurrence of a health condition.
D. Screening for a pediculosis breakout: Screening is a secondary prevention activity because it involves early detection of an existing condition (lice infestation). It does not prevent the initial occurrence of disease, so it is not a primary prevention topic.
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