An older client with heart failure (HF), coronary artery disease (CAD), and hypertension (HTN) is receiving these daily prescriptions: atenolol, furosemide, and enalapril. Which assessments should the nurse include in evaluating the effectiveness of the medications? (Select all that apply.)
Heart sounds.
Blood pressure.
Bowel sounds.
Daily weight.
Range of motion.
Correct Answer : A
Choice A reason:
Heart sounds: Monitoring heart sounds is crucial for evaluating the effectiveness of medications in a client with heart failure and coronary artery disease. Changes in heart sounds, such as the presence of new murmurs or gallops, can indicate worsening heart failure or other cardiac complications1. Regular assessment helps in early detection and management of potential issues.
Choice B reason:
Blood pressure: Blood pressure monitoring is essential for clients with hypertension and those taking medications like atenolol and enalapril. These medications are used to manage blood pressure and reduce the workload on the heart. Regular monitoring ensures that the medications are effectively controlling blood pressure within the target range, typically less than 130/80 mm Hg.
Choice C reason:
Bowel sounds: While assessing bowel sounds is important for overall health, it is not directly related to evaluating the effectiveness of heart failure, CAD, or hypertension medications. Bowel sounds are more relevant in gastrointestinal assessments and do not provide specific information about the effectiveness of the prescribed cardiac medications.
Choice D reason:
Daily weight: Monitoring daily weight is a key assessment for clients with heart failure. Sudden weight gain can indicate fluid retention, which is a sign of worsening heart failure. Furosemide, a diuretic, helps manage fluid balance, and daily weight monitoring helps evaluate its effectiveness in preventing fluid overload.
Choice E reason:
Range of motion: Assessing range of motion is important for overall mobility and physical health but is not directly related to evaluating the effectiveness of medications for heart failure, CAD, or hypertension. It is more relevant in musculoskeletal assessments and rehabilitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Use a straw to ingest: Ferrous sulfate elixir can cause staining of the teeth. Using a straw helps to minimize contact with the teeth, thereby reducing the risk of staining. This method ensures that the medication is ingested directly into the throat, bypassing the teeth.
Choice B Reason:
Swallow undiluted: Swallowing ferrous sulfate elixir undiluted is not recommended because it can cause gastrointestinal irritation. Diluting the elixir in water or juice can help to minimize this irritation and improve absorption.
Choice C Reason:
Mix with an antacid: Mixing ferrous sulfate with an antacid is not advisable because antacids can interfere with the absorption of iron. Iron is best absorbed in an acidic environment, and antacids neutralize stomach acid, thereby reducing iron absorption.
Choice D Reason:
Take with a glass of milk: Taking ferrous sulfate with milk is not recommended because calcium in milk can inhibit the absorption of iron. It is best to take iron supplements on an empty stomach or with a source of vitamin C, such as orange juice, to enhance absorption
Correct Answer is ["0.8"]
Explanation
Calculation Steps
Step 1: Identify the concentration of the medication in the syringe.
The syringe is labeled “Enoxaparin sodium injection, USP 60 mg/0.6 mL.”
Step 2: Calculate the amount of medication per mL.
60 mg ÷ 0.6 mL = 100 mg/mL
Result = 100 mg/mL
Step 3: Determine the prescribed dose.
The prescribed dose is 80 mg.
Step 4: Calculate the volume to administer.
80 mg ÷ 100 mg/mL = 0.8 mL
Result = 0.8 mL
Therefore, the nurse should administer 0.8 mL.
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