A nurse is caring for a patient who is prescribed furosemide for the treatment of heart failure. The patient reports weakness, dizziness, and increased thirst. The nurse notes a significant decrease in blood pressure and a potassium level 130 on assessment. Which action should the nurse prioritize?

• Holding the next dose of furosemide and notifying the healthcare provider.

• Continue to monitor the patient for further symptoms.

• Encouraging the patient to increase dietary potassium intake

• Administering a potassium-sparing diuretic.

A nurse is providing education to a patient who has been prescribed warfarin for anticoagulation therapy. Which statement by the patient indicates an understanding of the education provided regarding warfarin therapy? SELECT ALL THAT APPLY

• "I should avoid making significant changes to my diet, especially with green leafy vegetables."

• "I should have regular blood tests to monitor my international normalized ratio (INR)."

• "I need to notify my healthcare provider if I experience unusual bleeding or bruising."

• "I can take over-the-counter pain relievers like ibuprofen for headaches."

• "I will use my manual razor when shaving."

A nurse is caring for a patient on long-term warfarin therapy for a mechanical valve. The most recent INR result is 3.2. What is the nurse's priority action?

• Hold the next dose and notify the healthcare provider

• Administer the current regimen

• Administer vitamin K

• Administer higher dose

A three year old brought to the ED with difficulty breathing and shortness of breath. What vital signs would need to be reported upon assessment?

• HR 122, RR 32, Temp 99.9

• HR 60, RR 12, Temp 100.2

• HR 100, RR 19, Temp 97.7

• HR 115, RR 25, Temp 99.1

17. The nurse should expect to include bed rest, a high- calorie diet, and extra fluids in the care plan for a client with which disorder?

• Cystic Fibrosis

• Pneumothorax

• Pneumonia

• RSV

A nurse is caring for a patient with asthma who is prescribed albuterol (a short-acting beta-2 agonist) via a metered-dose inhaler (MDI). What is the nurse's primary teaching point regarding the use of albuterol?

• "Wait at least 1 minute between puffs if a second dose is needed."

• 
  

  "Take albuterol with food to reduce the risk of gastrointestinal upset."

• 
  "Use albuterol only during an asthma attack, not for prevention."

• "Use albuterol as a daily preventive medication for asthma.

The client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. The priority assessment is for the nurse to

• Check that the balloon is deflated on a regular basis

• Monitor IV fluids for the shift

• Check that the hemostat is on the bedside

• Regularly assess respiratory status

The nurse is caring for a client with liver cirrhosis. Which of the following assessment findings leads you to suspect hepatic encephalopathy in her?

• Trousseau’s sign

• Hepatojugular reflex

• Asterixis

• Chvostek’s sign

The student nurse is teaching the family of a patient with liver failure. You instruct them to limit which foods in the patient’s diet?

• Potatoes and pastas

• Butter and gravies

• Meats and beans

• Cakes and pastries

Stephen is a 62 y.o. patient that has had a liver biopsy. Which of the following groups of signs alert you to a possible pneumothorax?

• Fever, rebound tenderness, and abdominal rigidity

• Dyspnea and reduced or absent breath sounds over the right lung

• Redness, warmth, and drainage at the biopsy site

• Tachycardia, hypotension, and cool, clammy skin