A nurse is required to monitor a client with dysrhythmia during the administration of isoproterenol. Which of the following nursing interventions will help to determine the drug response?

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Monitor fluid intake and output. When administering isoproterenol to a client with dysrhythmia, monitoring fluid intake and output is crucial because isoproterenol, a non-selective beta-adrenergic agonist, can increase heart rate and cardiac output, leading to increased fluid loss through diuresis. Monitoring fluid intake and output allows the nurse to assess the client's hydration status, renal function, and the effect of the medication on fluid balance. Option A) Monitor vital signs is a general assessment approach and may not provide specific information on the drug's response related to fluid balance. Option B) Closely monitor the pulse rate is important when administering isoproterenol, but it focuses solely on one aspect of the drug response (heart rate) and does not address the potential fluid imbalances. Option C) Monitor blood pressure is essential when administering isoproterenol due to its potential effects on blood pressure, but it does not directly assess the drug's impact on fluid balance. Educational context: Understanding the rationale behind monitoring fluid intake and output when administering medications that can affect fluid balance is crucial for nurses caring for patients with cardiovascular conditions. By monitoring fluid status, nurses can detect early signs of fluid overload or dehydration, assess renal function, and evaluate the effectiveness and side effects of medications impacting fluid balance. This holistic approach to patient assessment enhances patient safety and contributes to optimal outcomes in cardiovascular care.

Correct Answer: B

Rationale: The most appropriate dietary recommendation for a patient diagnosed with Coronary Artery Disease (CAD) is option B: Decreased intake of sodium, animal, other fats, overall calories, and increase dietary fiber. This recommendation is based on evidence-based guidelines for managing CAD. Reducing sodium intake helps lower blood pressure and decrease the risk of heart disease. Limiting animal fats and overall calorie intake can help lower cholesterol levels and reduce the risk of atherosclerosis. Increasing dietary fiber can aid in improving cholesterol levels and promoting overall heart health. Option A is incorrect because a diet high in simple carbohydrates can lead to elevated blood sugar levels and contribute to weight gain, both of which are risk factors for CAD. Option C is not ideal because high-protein intake, limited dairy products, and specific restrictions on sodium, potassium, and phosphorus are not typically recommended as the primary dietary interventions for CAD. In an educational context, it is important for healthcare professionals to understand the relationship between diet and cardiovascular health to provide evidence-based recommendations to patients with CAD. Teaching patients about heart-healthy dietary habits can empower them to make positive lifestyle changes that support their heart health and overall well-being.

Correct Answer: B

Rationale: The correct initial action for the cardiac-vascular nurse in this scenario is option B: inquire about the patient's medication compliance. This is the most appropriate step because the patient has presented with signs of fluid retention (pedal edema, weight gain) and a decreased ejection fraction, indicating potential heart failure exacerbation. By assessing the patient's medication compliance, the nurse can determine if the prescribed medications (digoxin, furosemide, enalapril) are being taken as directed, as non-compliance could lead to worsening heart failure symptoms. Option A is incorrect because simply documenting the weight and waiting until the next session could delay necessary interventions if the patient's condition is deteriorating. Option C is not the initial action as the nurse should first gather more information before involving the physician. Option D is also not the priority as reviewing the nuclear scan is not as immediate as assessing medication compliance in this situation. From an educational perspective, this question highlights the importance of medication adherence in managing heart failure and the need for timely assessment and intervention in patients showing signs of decompensation. It emphasizes the role of nurses in monitoring patients' conditions and taking appropriate actions to prevent further complications.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) reduces the pressure on the puncture site. This is the appropriate action because the patient is experiencing symptoms of arterial insufficiency due to compression device-related complications. By reducing pressure on the puncture site, the nurse can restore circulation and prevent further ischemic damage to the hand. Option A is incorrect because calling the physician may cause a delay in addressing the immediate issue of compromised circulation. Option B, performing an Allen test, is not necessary at this point as the symptoms already indicate arterial insufficiency. Option D, using Doppler ultrasound, is not the most urgent intervention needed to address the acute ischemic symptoms in the patient's hand. Educationally, this question assesses the nurse's ability to recognize and respond to complications following a cardiac catheterization procedure. It reinforces the importance of prompt assessment and intervention in managing post-procedural complications to prevent potential complications like ischemia and tissue damage. It also highlights the critical thinking skills required in assessing and managing vascular access-related issues in cardiovascular care.

Correct Answer: B

Rationale: In hypertension, the most common cause of organ damage is related to atherosclerotic changes in vessels that supply the organs. This is the correct answer (B) because hypertension leads to increased pressure within the blood vessels, causing them to undergo structural changes like thickening and hardening of the arterial walls. These changes can lead to atherosclerosis, where plaques build up and narrow the blood vessels, reducing blood flow to organs and tissues. Option A is incorrect because while increased fluid pressure against organ tissue can contribute to damage, it is not the primary mechanism in hypertension-related organ damage. Option C is incorrect as erosion and thinning of blood vessels from constant pressure is not the main pathophysiological process seen in hypertension. Option D is also incorrect as increased hydrostatic pressure causing leakage of plasma into organ interstitial spaces is not the primary cause of organ damage in hypertension. From an educational perspective, understanding the link between hypertension and atherosclerosis is crucial for healthcare professionals to effectively manage and prevent complications in patients with high blood pressure. Knowing how hypertension impacts the vascular system and organ health is essential for providing comprehensive care and educating patients on risk factors and lifestyle modifications to mitigate these effects.