A nurse is caring for a client who is intubated and receiving mechanical ventilation for heroin toxicity. Which of the following assessments is the nurse's priority?

WBC count

Intake and output

ABGs

Blood glucose level

Answer and Explanation

The Correct Answer is C

Rationale:

A. WBC count: Monitoring the white blood cell count is useful for detecting infection, but heroin toxicity primarily affects the respiratory system. An elevated or normal WBC does not provide immediate information about the client's ventilation or gas exchange status.

B. Intake and output: Tracking fluid balance is important for overall patient monitoring, especially in critically ill clients. However, it does not provide direct insight into the effectiveness of mechanical ventilation or the client's oxygenation status.

C. ABGs: Arterial blood gases are the priority assessment because they directly measure the client's oxygenation, ventilation (CO₂ removal), and acid-base status. Since heroin toxicity can cause respiratory depression, ABGs are essential to evaluate the effectiveness of mechanical ventilation.

D. Blood glucose level: Although monitoring glucose is important in critically ill clients, heroin use is not typically associated with hypo- or hyperglycemia. Blood glucose assessment is not as urgent as evaluating respiratory function in this scenario.

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Correct Answer is ["A","B","C","D","E","F","G"]

Explanation

Rationale:

Client reports chest pain as 4 on a scale of 0 to 10: Chest pain, even when moderate, is a red flag symptom for possible myocardial ischemia, especially in a high-risk client. Prompt evaluation is essential to rule out unstable angina or early myocardial infarction.
Client reports fatigue over the last several months: Chronic fatigue may be an early and often overlooked symptom of cardiovascular disease in women. In the context of other cardiac risk factors, this requires further cardiac workup.
Client reports intermittent epigastric discomfort upon exertion: Epigastric discomfort on exertion may reflect angina equivalents, especially in women and diabetic patients. It may indicate myocardial ischemia and requires immediate attention.
Client reports experiencing occasional nausea and heart palpitations: Nausea and palpitations may be atypical symptoms of cardiac ischemia or arrhythmias. These signs are concerning when paired with chest discomfort and cardiovascular history.
History of smoking 1 pack per day for the past 30 years: Smoking is a major modifiable risk factor for coronary artery disease. Long-term tobacco use contributes to endothelial dysfunction and increases the risk of acute cardiac events.
Past medical history of type 2 diabetes mellitus, systemic lupus erythematosus, hypertension, and hyperlipidemia: This cluster of comorbidities places the client at extremely high risk for cardiovascular complications. Each condition independently contributes to atherosclerosis and cardiac event risk.
Father died at age 50 with coronary artery disease:A strong family history of premature CAD significantly elevates this client’s cardiac risk. It intensifies the concern for hereditary predisposition to cardiovascular events.

A. Ferrous sulfate B. Aspirin C. Naproxen D. Echinacea E. Dextromethorphan

Correct Answer is ["B","C","D"]

Explanation

Rationale:
A. Ferrous sulfate: Ferrous sulfate is an iron supplement and does not directly interact with warfarin's anticoagulant effect. While some mild interactions are possible, it is not generally contraindicated unless specifically advised due to individual clinical conditions.

B. Aspirin: Aspirin has antiplatelet effects and can increase the risk of bleeding when taken with warfarin. The combination enhances anticoagulation and significantly raises the chance of gastrointestinal or systemic bleeding.

C. Naproxen: Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that can interfere with platelet function and irritate the gastrointestinal lining, increasing the risk of bleeding when combined with warfarin.

D. Echinacea: Echinacea may interfere with liver enzyme activity and affect the metabolism of warfarin, potentially altering its effectiveness. Herbal supplements can cause unpredictable interactions and should generally be avoided while on warfarin.

E. Dextromethorphan: Dextromethorphan is a common cough suppressant and does not have significant interactions with warfarin. It is generally considered safe for occasional use in clients taking anticoagulants.

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A nurse is caring for a client who is intubated and receiving mechanical ventilation for heroin toxicity. Which of the following assessments is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D","E","F","G"]

Explanation

A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following medications should the nurse instruct the client to avoid? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

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