A client presents to the emergency department complaining of headaches and blurred vision. The client's vital signs are as follows, Pulse 102 beats/minute, BP 172/92. RR 20 breaths/minute, SpO2.97% on room air temperature of 98.64. Which of the following interventions would be most appropriate for this patient?

Administer IV hydralazine and monitor blood pressure

Administer oxygen at 10 liters/minute by non rebreather mask

Administer acetaminophen 650 mg PO re-check temperature

Infuse 0.9% sodium chioride at 120 mL/hour

Answer and Explanation

The Correct Answer is A

A) "Administer IV hydralazine and monitor blood pressure":
. The patient's elevated blood pressure (172/92 mmHg), along with headaches and blurred vision, could indicate a hypertensive emergency, a serious condition where extremely high blood pressure can cause acute organ damage. Hydralazine is a common intravenous antihypertensive medication used to lower blood pressure quickly in these situations. The nurse should administer hydralazine as prescribed and closely monitor the blood pressure to prevent complications like stroke, heart failure, or kidney damage. Blood pressure management is the priority, as the patient's symptoms are likely related to the elevated BP.

B) "Administer oxygen at 10 liters/minute by non-rebreather mask":
. While oxygen therapy may be appropriate for patients with respiratory distress or hypoxia, the patient's SpO2 is 97% on room air, indicating that there is no immediate oxygenation issue. Administering oxygen unnecessarily could lead to oxygen toxicity, and it is not the priority in this case. The patient's main concern is their elevated blood pressure, which requires urgent management.

C) "Administer acetaminophen 650 mg PO re-check temperature":
. While headaches are one of the patient's complaints, there is no indication of fever (the temperature is 98.6°F). Administering acetaminophen would be appropriate for pain relief, but it is not the priority in this case. The elevated blood pressure and potential hypertensive emergency are the primary issues that need to be addressed first.

D) "Infuse 0.9% sodium chloride at 120 mL/hour":
. Normal saline (0.9% sodium chloride) is typically used for hydration, but there is no indication that the patient is dehydrated or that intravenous fluids are the priority. In cases of hypertensive emergency, the goal is to lower blood pressure using antihypertensive medications, not to infuse fluids. Fluid administration could potentially worsen the situation if the elevated blood pressure is not addressed first.

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Correct Answer is B

Explanation

A) "The test will use a catheter to assess for blocked coronary arteries": This statement is incorrect. An echocardiogram does not involve the use of a catheter. It is a non-invasive imaging test that uses sound waves (ultrasound) to create images of the heart's structure and function. Assessing for blocked coronary arteries typically requires a different procedure, such as a coronary angiogram, which involves the use of a catheter.

B) "The test can show how well your heart pumps blood.": This is the correct statement. An echocardiogram is primarily used to assess how well the heart is functioning, including how effectively it pumps blood. It can provide detailed images of the heart's chambers, valves, and blood flow, helping to evaluate conditions such as heart failure, valve dysfunction, and other structural issues that may impair the heart’s ability to pump blood efficiently.
C) "The test will show proteins in the blood from damaged heart muscle.": This statement is incorrect. An echocardiogram does not measure blood proteins or markers from damaged heart muscle. Blood tests, such as troponin levels, are used to detect proteins released from heart muscle after injury, such as in a heart attack. The echocardiogram focuses on the heart's structure and function, not the chemical markers in the blood.

D) "The test shows the electrical activity of the heart from multiple angles.": This statement is inaccurate. The electrical activity of the heart is assessed by an electrocardiogram (ECG or EKG), not an echocardiogram. An ECG records the heart's electrical signals, while an echocardiogram uses sound waves to visualize the heart's anatomical structure and function.

A. "Following up with your dentist frequently will be important. B. Take an ant acid with the medication if indigestion occurs. C. *Alcoholic beverages should be limited to 1-2 per day while taking phenytoin.* D. "Phenytoin may turn your urine orange

Correct Answer is A

Explanation

A. "Following up with your dentist frequently will be important.":
This is the correct and important advice to give. Phenytoin (Dilantin), an anticonvulsant, can cause gum overgrowth (gingival hyperplasia), which makes it important for the patient to have regular dental check-ups. Poor oral hygiene combined with gingival hyperplasia can increase the risk of infection and other oral health issues. Therefore, advising the patient to follow up frequently with a dentist is essential to manage this side effect.

B. "Take an antacid with the medication if indigestion occurs.":
advice. Taking an antacid with phenytoin can interfere with its absorption. Antacids, especially those containing aluminum or magnesium, can reduce the effectiveness of phenytoin, leading to suboptimal therapeutic levels. It’s important to separate phenytoin from antacids by at least 2 hours to avoid this interaction. Therefore, antacids should not be used with phenytoin to manage indigestion.

C. "Alcoholic beverages should be limited to 1-2 per day while taking phenytoin.":
This is inaccurate advice. Alcohol can significantly affect the metabolism of phenytoin, increasing the risk of both toxicity and reduced effectiveness. Alcohol may lower the seizure threshold and interfere with the therapeutic effect of phenytoin, especially in higher amounts. Therefore, it is generally recommended that patients taking phenytoin avoid alcohol altogether, or at the very least limit consumption significantly and discuss it with their healthcare provider.

D. "Phenytoin may turn your urine orange.":
information. Phenytoin does not cause urine to turn orange. Urine discoloration can occur with some medications (like rifampin, for example), but not with phenytoin. This statement could cause unnecessary confusion for the patient. It is essential to provide accurate information to avoid misconceptions about medication side effects.

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Naxlex Comprehensive Predictor Exams

The nurse is preparing a client for an echocardiogram. The client asks what the test can show Which of the following is a correct statement?

Correct Answer is B

Explanation

A nurse is providing teaching to a client who has seizures and a new prescription for phenytoin. Which of the following information should the nurse provide?

Correct Answer is A

Explanation

The nurse is caring for a client experiencing acute hyperglycemia. The nurse would expect all of the following interventions except which?

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