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The nurse has reviewed the Nurses' Notes, Diagnostic Results, and Laboratory Results.

Exhibits
Select the 3 prescriptions the nurse should prescribe.

Enoxaparin 80 mg subcutaneous twice a

Potassium chloride 20 mEq PO twice a day

Ciprofloxacin 750 mg PO twice a day

Enalapril 5 mg PO daily

Rosuvastatin 20 mg PO daily

Digoxin 0.25 mg PO daily

Metformin 850 mg PO daily

Albuterol 2 puffs every 4 to 6 hr as needed

Answer and Explanation

Correct Answer : B,D,E,G

Rationale:

A. Enoxaparin 80 mg subcutaneous twice a day: Enoxaparin is an anticoagulant used for prevention or treatment of thromboembolic events. There is no indication from the client’s current labs, vitals, or diagnostics (D-dimer within normal limits, no evidence of clot) to initiate anticoagulation at this time.

B. Potassium chloride 20 mEq PO twice a day: The client’s potassium level is 3.6 mEq/L, which is at the lower end of the normal range. Supplementation may be warranted, particularly if antihypertensive therapy such as a diuretic is initiated, to prevent hypokalemia and maintain cardiac stability.

C. Ciprofloxacin 750 mg PO twice a day: There is no evidence of bacterial infection in the client’s assessment, labs, or diagnostics. Prescribing an antibiotic is unnecessary and not indicated.

D. Enalapril 5 mg PO daily: The client’s blood pressure is 164/92 mm Hg, which is hypertensive. Enalapril, an ACE inhibitor, is appropriate to manage hypertension, reduce cardiovascular risk, and potentially improve renal outcomes given the family history of renal failure.

E. Rosuvastatin 20 mg PO daily: The client has significantly elevated cholesterol (total cholesterol 280 mg/dL, LDL 220 mg/dL, HDL 20 mg/dL) and triglycerides 220 mg/dL. Initiating a statin is appropriate to reduce cardiovascular risk and manage hyperlipidemia.

F. Digoxin 0.25 mg PO daily: The client does not exhibit heart failure symptoms or arrhythmias that require digoxin at this time. ECG shows only sinus tachycardia without S-T changes, so digoxin is not indicated.

G. Metformin 850 mg PO daily: The client’s glucose is 310 mg/dL and HbA1c is 7%, indicating diabetes mellitus. Initiating metformin is appropriate for glycemic control and to reduce the risk of complications associated with hyperglycemia.

H. Albuterol 2 puffs every 4 to 6 hr as needed: The client’s lungs are clear on auscultation, and there is no active respiratory distress. Albuterol is not indicated for ongoing therapy in this assessment.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

Rationale:

• Difficulty walking: Bone injury limits weight-bearing ability and causes alterations in gait. Localized pain and instability can make ambulation difficult. Clients often compensate with limping to avoid pressure on the injured limb. In DVT, A clot in the deep veins causes swelling and discomfort, making ambulation painful. The heaviness and fullness in the limb interfere with normal gait. Clients may develop a limp due to localized tenderness.

• Pain: A fracture typically produces sharp, localized pain that worsens with movement. Tissue disruption and swelling contribute to discomfort. The pain limits limb use and is often immediate after injury. DVT often causes aching or cramping pain in the affected limb, especially with walking. Venous congestion and inflammation contribute to tenderness. Pain increases when the calf is compressed or when standing.

• Limb heaviness: Venous obstruction causes blood pooling, producing a heavy and tight sensation. This finding reflects impaired venous return, especially when swelling is also present. It is common in unilateral DVT. A fracture typically causes sharp, localized pain rather than diffuse heaviness. Heaviness is more strongly associated with venous congestion.

• Fever: Low-grade fever may occur due to inflammatory response around the thrombus. Cytokine release produces systemic symptoms during clot formation. It can accompany swelling, warmth, and redness. A simple fracture does not generally cause systemic fever unless infection develops. Fever is more indicative of inflammatory or infectious conditions.

• Edema: Venous blockage leads to unilateral swelling due to trapped fluid and elevated venous pressure. The affected limb becomes warm, enlarged, and firm. This is a hallmark finding in deep vein thrombosis. While swelling may occur after a fracture, the client’s presentation shows significant unilateral edema matching venous obstruction.

A. Restrict daily exercise B. Encourage 3 large meals per day. C. Limit dietary salt intake D. Obtain weight once per week.

Correct Answer is C

Explanation

Rationale:

A. Restrict daily exercise: Clients with heart failure benefit from regular, moderate activity as tolerated to improve cardiac efficiency and prevent deconditioning. Restricting all exercise can worsen functional status and is not recommended unless specifically limited by the healthcare provider.

B. Encourage 3 large meals per day: Large meals can increase cardiac workload and exacerbate heart failure symptoms due to increased blood flow demands during digestion. Smaller, more frequent meals are preferable to reduce strain on the heart.

C. Limit dietary salt intake: Reducing sodium intake helps prevent fluid retention and edema, which can exacerbate heart failure and increase cardiac workload. Teaching clients to limit salt is a key intervention to manage decreased cardiac output and maintain stable fluid balance.

D. Obtain weight once per week: Daily weight monitoring is recommended for clients with heart failure to detect fluid retention early. Weekly weights may delay recognition of sudden fluid accumulation, increasing the risk of decompensation.

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The nurse has reviewed the Nurses' Notes, Diagnostic Results, and Laboratory Results. Exhibits Select the 3 prescriptions the nurse should prescribe.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

A nurse is providing teaching to a client who has heart failure and a decreased cardiac output. Which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

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The nurse has reviewed the Nurses' Notes, Diagnostic Results, and Laboratory Results.

Exhibits
Select the 3 prescriptions the nurse should prescribe.