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 ["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.
Correct Answer is D
Explanation
Choice A reason: A complete blood count (CBC) is not typically required before starting statin therapy. While a CBC can provide valuable information about a patient’s overall health, it does not specifically relate to the potential side effects or necessary monitoring for statin use. Statins primarily affect the liver, so monitoring liver function is more critical.
Choice B reason: Serum electrolytes are important for assessing overall metabolic and kidney function, but they are not directly related to the initiation of statin therapy. Statins do not typically affect electrolyte levels, so this test is not necessary before starting the medication.
Choice C reason: Capillary blood glucose levels are important for monitoring diabetes and blood sugar control. While statins can have an impact on blood glucose levels, this is not the primary concern when initiating therapy. Monitoring liver function is more directly related to the potential side effects of statins.
Choice D reason: Serum liver enzymes are crucial to review before starting statin therapy. Statins can cause liver enzyme elevations, indicating liver damage or dysfunction. Therefore, baseline liver enzyme levels should be obtained to monitor for any potential hepatotoxicity during treatment.
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