A patient with a history of heart failure is prescribed a beta-blocker. Which assessment finding indicates a therapeutic effect of beta-blocker therapy?

Correct Answer: A

Rationale: Beta-blockers are medications commonly used in the management of heart failure. One of the therapeutic effects of beta-blockers is to decrease the heart rate. By blocking the action of adrenaline on the heart, beta-blockers help to slow down the heart rate, reduce the workload on the heart, and improve overall heart function. In patients with heart failure, a decreased heart rate is a favorable outcome as it can help improve cardiac output and reduce symptoms of heart failure such as fatigue and shortness of breath. Monitoring the heart rate is an important assessment parameter to evaluate the effectiveness of beta-blocker therapy in patients with heart failure. Therefore, a decreased heart rate would indicate a therapeutic effect of beta-blocker therapy in this patient.

Correct Answer: B

Rationale: Beta-blockers work by blocking the effects of adrenaline on beta receptors in the body. One common adverse effect of beta-blockers is bradycardia, or a slowed heart rate. Since the patient is being prescribed a beta-blocker for migraine headaches, it is important for the nurse to monitor closely for signs and symptoms of bradycardia such as dizziness, fatigue, and fainting. Monitoring the heart rate regularly and reporting any significant decrease to the healthcare provider is essential to prevent complications associated with bradycardia. Compared to the other options, bradycardia is the most relevant adverse effect to monitor in a patient prescribed a beta-blocker.

Correct Answer: A

Rationale: Pressure injuries on the heels are a concern as they can develop quickly and lead to serious complications, especially in surgical patients who are immobile for extended periods. Applying pressure-relieving devices, such as heel protectors or foam dressings, can help alleviate the pressure on the affected areas and prevent further damage. These devices are designed to distribute pressure evenly and reduce the risk of pressure injuries. It is important for the nurse to address the issue promptly to prevent additional harm to the patient's skin integrity.

Correct Answer: C

Rationale: In this situation, it is crucial for the nurse to inform the surgeon immediately and request corrective action. Maintaining a sterile field during surgical procedures is essential to prevent infections and ensure patient safety. Any break in sterile technique should be addressed promptly to prevent any potential harm to the patient. By informing the surgeon immediately, corrective action can be taken promptly to maintain the sterility of the surgical field and minimize the risk of complications. Reporting the incident to the surgeon also allows for immediate intervention and re-education of the team member involved in the break in sterile technique.

Correct Answer: B

Rationale: In a situation where a patient's temperature is dropping below the normal range during surgery, the nurse should prioritize actively warming the patient to prevent hypothermia. Administering a warming blanket or using a forced-air warming device are effective methods to increase the patient's body temperature and prevent any complications that may arise from hypothermia. Increasing the ambient room temperature can help, but it may not be as direct or effective as applying targeted heat sources to the patient. Documenting the temperature trend in the patient's chart is important for record-keeping purposes, but immediate action to address the dropping temperature is necessary. Continuously monitoring the patient's temperature closely is important, but action should be taken promptly to prevent further decline.