A 78-year-old man is admitted with deterioration of chronic heart failure. He is house-bound and has had three similar admissions in the past nine months. There is a history of ischaemic heart disease. His medication comprises furosemide, ramipril in full dose, valsartan, spironolactone, simvastatin and aspirin. He is dyspnoeic on minimal exertion, looks unwell, pulse 100/min regular, BP 90/70 mmHg, jugular venous pressure (JVP) is at 4 cm, gallop rhythm, chest clear, pretibial oedema. ECG shows sinus rhythm, an old inferior infarct and poor anterior R wave progression. Serum urea 15 mmol/L, creatinine 90 μmol/L, Na+ 140, K+ 4.6. Which of the following would be most appropriate?

Correct Answer: C

Rationale: Chronic heart failure (CHF) decompensation needs optimization. Morphine relieves acute dyspnea but not chronic management here. Hydralazine/isosorbide reduces afterload/preload, useful in advanced CHF, but less immediate. Carvedilol, a beta-blocker, risks decompensation with low BP. Metolazone, a potent diuretic, aids fluid overload but overlaps with furosemide. Digoxin improves contractility and rate control in sinus rhythm CHF, reducing hospitalizations, most appropriate given his recurrent admissions and stable renal function. Its inotropic benefit stabilizes this patient, enhancing quality of life.

Correct Answer: C

Rationale: Nystatin is an antifungal medication used to treat fungal infections, such as candidiasis. Before administration, assessing whether the client could be pregnant is critical because nystatin's safety in pregnancy is not fully established (Category C), meaning potential risks to the fetus cannot be ruled out without further evaluation. This makes pregnancy status a key safety consideration to prevent harm to an unborn child, outweighing other factors in urgency. The type of diet or amount of fat might influence general health or drug absorption minimally but isn't directly critical to nystatin's administration. Height and weight could affect dosing in some medications, but nystatin's dosing is typically standard and not weight-based for most fungal infections. Thus, confirming pregnancy status ensures the drug's safety profile aligns with the client's condition, making choice C the most critical assessment data to review prior to administration.

Correct Answer: B

Rationale: Tricyclic antidepressants (TCAs) like imipramine block norepinephrine and serotonin reuptake, but their anticholinergic effects are significant. In glaucoma, particularly angle-closure type, these effects can increase intraocular pressure by dilating pupils and obstructing aqueous humor outflow, risking acute attacks—thus, they're contraindicated. TCAs lower seizure threshold, lacking anticonvulsant activity, and may exacerbate epilepsy. They don't enhance levodopa absorption; rather, they might interact via monoamine pathways, but this isn't a primary effect. Some TCAs (e.g., amitriptyline) have quinidine-like sodium channel blockade, giving antiarrhythmic properties, but this isn't their primary use. The glaucoma concern is critical due to the anticholinergic mechanism, making it a key clinical consideration and the most accurate statement here.

Correct Answer: A

Rationale: Cefotaxime, a third-generation cephalosporin, treats postoperative infections but disrupts gut flora, commonly causing diarrhea due to overgrowth of pathogens like Clostridioides difficile. This adverse effect can range from mild to life-threatening pseudomembranous colitis, making it a priority observation. Headache might occur but is less frequent and specific to cefotaxime. Constipation contrasts with its GI effects, as diarrhea is more typical, while tachycardia could signal anaphylaxis or secondary infection but isn't a primary concern. Monitoring for diarrhea allows early detection of complications, enabling prompt intervention like discontinuing the drug or starting probiotics. This focus aligns with cephalosporins' pharmacological profile, where GI disturbance is a well-documented risk, especially post-surgery when patients are vulnerable. Thus, observing for diarrhea is the nurse's key assessment, ensuring patient safety and effective management of adverse effects, making A the correct choice.

Correct Answer: B

Rationale: Mitoxantrone for MS progression risks hepatitis . This chemotherapeutic damages liver cells, requiring monitoring. Anxiety , hypopyrexia , muscle strength , and leukocytosis (E) aren't primary. Hepatotoxicity, with cardiotoxicity, is a key concern in this worsening MS case.