A client with juvenile pilocytic astrocytoma who is receiving dexamethasone (Decadron) 4mg/IV

Correct Answer: D

Rationale: Juvenile pilocytic astrocytoma is a type of brain tumor that can cause neurological symptoms such as changes in cognition and personality. A sudden change in the client no longer recognizing a family member could indicate a worsening of the tumor or potential complications from the treatment with dexamethasone. This change in cognition should raise immediate concern for the nurse as it may signal a decline in the client's neurological status requiring prompt assessment and intervention. The other options are also important to monitor, but the change in cognition is the most concerning as it suggests a more immediate and potentially serious issue.

Correct Answer: C

Rationale: When teaching a patient how to use sublingual nitroglycerin, it is essential to include the instruction that if the chest pain is not relieved after one tablet, they should call 911 immediately. This is because persistent chest pain could indicate a serious cardiac event, such as a heart attack, that requires immediate medical attention. It is not advisable to take multiple doses without consulting a healthcare provider, as this can lead to complications. The patient should seek emergency medical help if their symptoms are not relieved after taking one tablet of sublingual nitroglycerin.

Correct Answer: C

Rationale: When a patient is receiving antidysrhythmics, there is a risk of fluid and electrolyte disturbances due to the medication's effects on the heart's electrical activity. Antidysrhythmics can cause arrhythmias, which can impact cardiac output and blood pressure, potentially leading to fluid volume deficits. It is essential for nurses to monitor the patient's fluid balance closely and address any deficits promptly to prevent complications. Therefore, the nursing diagnosis of Deficient fluid volume is most appropriate for a patient receiving antidysrhythmics.

Correct Answer: D

Rationale: The nurse's priority action would be to discontinue the infusion immediately and notify the prescriber. The patient developing chills and back pain during a blood transfusion may be signs of a transfusion reaction, possibly indicating an incompatibility or adverse reaction to the blood product. It is crucial to stop the transfusion to prevent further complications and to notify the prescriber immediately so that appropriate interventions can be initiated promptly. Observing for other symptoms and slowing the infusion rate are secondary actions compared to discontinuing the infusion and informing the prescriber in this situation. Telling the patient that these symptoms are a normal reaction to the blood product is incorrect as the symptoms could indicate a serious issue that needs to be addressed promptly.

Correct Answer: C

Rationale: The response, "This drug is the first medication your health care provider will use to treat your angina," is accurate because Ranexa (ranolazine) is commonly used as a first-line treatment for chronic angina. It is typically prescribed when other angina medications, such as beta-blockers or calcium channel blockers, are not sufficient or well-tolerated by the patient. Ranexa works by helping the heart muscle to relax, which can improve blood flow to the heart and reduce angina symptoms. It is important for the patient to understand that Ranexa is specifically intended to treat angina and should not be used for other conditions without consulting their healthcare provider.