A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification?
Laboratory testing of serum potassium upon admission
Bumetanide 1 mg IV bolus every 12 hr
0.9% normal saline IV at 50 mL/hr continuous
Morphine sulfate 2 mg IV bolus every 2 hr PRN pain
The Correct Answer is C
Choice A Reason: This choice is incorrect because laboratory testing of serum potassium upon admission is an appropriate prescription for a client who has acute heart failure following MI. Serum potassium is an electrolyte that affects the cardiac function and rhythm. A normal serum potassium range is 3.5 to 5 mEq/L, and an abnormal level can indicate hypokalemia or hyperkalemia, which can cause arrhythmias, muscle weakness, or paralysis. Therefore, monitoring serum potassium is important to detect and correct any electrolyte imbalance and prevent complications.
Choice B Reason: This choice is incorrect because bumetanide 1 mg IV bolus every 12 hr is an appropriate prescription for a client who has acute heart failure following MI. Bumetanide is a loop diuretic that helps to reduce fluid retention and edema by increasing the urine output and sodium excretion. It may be used for clients who have heart failure, hypertension, or renal impairment, but it can cause hypokalemia, hypotension, or dehydration.
Therefore, administering bumetanide as prescribed can help to improve the cardiac output and reduce the preload and afterload.
Choice C Reason: This choice is correct because 0.9% normal saline IV at 50 mL/hr continuous is an inappropriate prescription for a client who has acute heart failure following MI. 0.9% normal saline is an isotonic solution that contains the same concentration of solutes as blood plasma. It may be used for clients who have fluid loss, dehydration, or shock, but it can worsen fluid overload and pulmonary edema in clients who have acute heart failure. Therefore, clarifying this prescription with the provider is necessary to prevent further deterioration of the client's condition.
Choice D Reason: This choice is incorrect because morphine sulfate 2 mg IV bolus every 2 hr PRN pain is an appropriate prescription for a client who has acute heart failure following MI. Morphine sulfate is an opioid analgesic that helps to relieve pain and anxiety by binding to the opioid receptors in the brain and spinal cord. It may be used for clients who have moderate to severe pain, dyspnea, or chest discomfort, but it can cause respiratory depression, hypotension, or nausea. Therefore, administering morphine sulfate as prescribed can help to reduce the oxygen demand and improve the cardiac function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because the client is not unconscious, as the GCS score ranges from 3 to 15, with 3 being the lowest possible score and indicating deep coma or death.
Choice B Reason: This is correct because the client can follow simple motor commands, as the GCS score for best motor response is 5, which means the client can localize pain by moving his limbs away from the source of stimulation.To interpret the Glasgow Coma Scale (GCS) score provided in the scenario:Eye Opening (E): 3 - The client opens their eyes in response to verbal stimuli.Best Verbal Response (V): 5 - The client is oriented and able to engage in coherent conversation.Best Motor Response (M): 5 - The client can localize pain or follow motor commands (depending on additional context). The total GCS score would be 3 + 5 + 5 = 13, indicating a mild level of impairment or responsiveness.
Choice C Reason: This is incorrect because the client is able to make vocal sounds, as the GCS score for best verbal response is 5, which means the client can orient himself to person, place, and time.
Choice D Reason: This is incorrect because the client does not open his eyes when spoken to, as the GCS score for eye opening is 3, which means the client only opens his eyes in response to pain.
Correct Answer is A
Explanation
Choice A: Evaluating chest expansion is the first action that the nurse should take, because it assesses the client's respiratory status and potential for pneumothorax, which is a life-threatening condition that can result from chest trauma. The nurse should compare the movement of both sides of the chest and listen for breath sounds.
Choice B: Checking pupillary response to light is an important action, but not the first one, because it assesses the client's neurological status and potential for brain injury. The nurse should observe the size, shape, and symmetry of the pupils and their reaction to light.
Choice C: Checking the client's response to questions about place and time is another important action, but not the first one, because it assesses the client's level of consciousness and orientation. The nurse should ask the client simple questions such as their name, date, and location.
Choice D: Assessing the capillary refill is a less important action, and not the first one, because it assesses the client's peripheral circulation and tissue perfusion. The nurse should press on the client's nail beds or fingertips and observe how quickly the color returns.
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