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.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: While it is true that breastfeeding is not recommended while taking isotretinoin due to the potential for adverse effects on the infant, this is not the most critical information for a client planning to become pregnant. The primary concern is the teratogenic effects of isotretinoin, which can cause severe birth defects.
Choice B reason: Advising the client not to take multiple vitamins that contain vitamin A while on isotretinoin is important because excessive vitamin A can increase the risk of toxicity. However, this is not the most crucial information for someone planning to become pregnant. The teratogenic risks of isotretinoin are a higher priority.
Choice C reason: Obtaining baseline liver function results is necessary during isotretinoin therapy due to the potential for hepatotoxicity. Regular monitoring helps ensure the liver is functioning properly. However, this information is secondary to the need to avoid pregnancy while on isotretinoin due to its severe teratogenic effects.
Choice D reason: Discontinuing isotretinoin one month before attempting to conceive is the most important information. Isotretinoin is highly teratogenic and can cause serious birth defects. It is crucial to stop the medication well before conception to ensure it is completely cleared from the body, reducing the risk of harm to the fetus.
Correct Answer is C
Explanation
Choice A reason:
Administering a PRN dose of an antianxiety drug might seem like a reasonable action if the tremors are related to anxiety. However, without a clear indication that anxiety is the cause of the tremors, this action could mask the underlying issue and delay appropriate treatment. It is essential to identify the root cause of the tremors before administering any medication.
Choice B reason:
Obtaining orthostatic blood pressure readings is a useful assessment for determining if the client has orthostatic hypotension, which can cause dizziness and fainting. However, this action is not directly related to the complaint of hand tremors. While it is a good practice to monitor vital signs, it does not address the immediate concern of tremors caused by pregabalin.
Choice C reason:
Notifying the healthcare provider is the most appropriate action. Tremors can be a side effect of pregabalin12. The healthcare provider needs to be informed to evaluate the severity of the side effect and decide whether to adjust the medication dosage or switch to an alternative treatment. This ensures that the client receives the most appropriate care and avoids potential complications.
Choice D reason:
Collecting a capillary glucose level is important for clients with diabetes or those at risk of hypoglycemia or hyperglycemia. However, there is no indication in the scenario that the client has diabetes or that blood glucose levels are related to the tremors. Therefore, this action is not directly relevant to the client’s current complaint.
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