An elderly client with heart failure arrives at the emergency room due to nausea, vomiting, and anorexia.
Based on the client’s signs and symptoms, which piece of data from the medical history is most significant when planning this client’s care?

The client underwent a coronary artery bypass procedure in 1995.

The client had a colonoscopy performed for routine screening six months ago.

The client suffered from depression following the death of their spouse in 1999.

The client has been taking digoxin and furosemide daily since 1996.

Answer and Explanation

The Correct Answer is D

Choice A rationale

While a coronary artery bypass procedure is a significant event in a patient’s medical history, it occurred in 1995, which is quite some time ago. Therefore, it may not be the most significant piece of data when planning this client’s care, given their current signs and symptoms.

Choice B rationale

A colonoscopy performed for routine screening six months ago is unlikely to be related to the client’s current symptoms of nausea, vomiting, and anorexia. Therefore, this choice is not the most significant piece of data when planning this client’s care.

Choice C rationale

Depression following the death of a spouse can significantly impact a person’s mental health. However, this event occurred in 1999, and while it may contribute to the client’s overall health status, it is not likely to be the most significant piece of data for planning care based on the client’s current symptoms.

Choice D rationale

The client has been taking digoxin and furosemide daily since 19962. Both of these medications are used to treat heart conditions. Digoxin strengthens the heart’s contractions, while furosemide is a diuretic that helps reduce fluid buildup. Given the client’s symptoms of nausea, vomiting, and anorexia, and their diagnosis of heart failure, this information is crucial. These symptoms could indicate a worsening of heart failure or side effects of the medication, which would significantly influence the plan of care.

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Correct Answer is C

Explanation

Choice A rationale

While it is important to assess for hypoglycemia between meals when a client is receiving insulin lispro, this is not the most important intervention. Hypoglycemia is a potential side effect of all insulins, but the timing of the hypoglycemia is often related to the timing of the insulin dose and meals.

Choice B rationale

Checking blood glucose levels every six hours is a part of diabetes management. However, this is not the most important intervention for a client who is receiving insulin lispro. The timing of blood glucose checks should be individualized based on the client’s needs and the type of insulin they are receiving.

Choice C rationale

Insulin lispro is a rapid-acting insulin that begins to work very quickly. For this reason, it should be given at the same time as meals. This is the most important intervention for a client who is receiving insulin lispro.

Choice D rationale

Keeping an oral liquid or glucose source available is important for all clients with diabetes to treat potential hypoglycemia. However, this is not the most important intervention for a client who is receiving insulin lispro.

A. Patient on Vancomycin. B. Patient on Sucralfate. C. Patient on Lorazepam. D. Patient on Digoxin.

Correct Answer is A

Explanation

Choice A rationale

Vancomycin is known to potentially cause nephrotoxicity, which can lead to acute kidney injury.

Choice B rationale

Sucralfate is not typically associated with acute kidney injury.

Choice C rationale

Lorazepam is not typically associated with acute kidney injury.

Choice D rationale

While digoxin can have many side effects, it’s not typically associated with acute kidney injury.

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An elderly client with heart failure arrives at the emergency room due to nausea, vomiting, and anorexia.Based on the client’s signs and symptoms, which piece of data from the medical history is most significant when planning this client’s care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which intervention is most important for the nurse to implement for a client who is receiving insulin lispro?

Correct Answer is C

Explanation

When administering medications to a group of patients, which patient should the nurse closely monitor for the development of acute kidney injury (AKI)?

Correct Answer is A

Explanation

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An elderly client with heart failure arrives at the emergency room due to nausea, vomiting, and anorexia.
Based on the client’s signs and symptoms, which piece of data from the medical history is most significant when planning this client’s care?