The client on amiodarone reports shortness of breath. What is the nurse's best response?

Correct Answer: A

Rationale: The correct answer is A: Notify the healthcare provider immediately. Shortness of breath in a client on amiodarone can indicate a serious side effect such as pulmonary toxicity or interstitial lung disease. The nurse should prioritize the client's safety by promptly informing the healthcare provider for further evaluation and management. This is crucial to prevent potential harm or worsening of the condition. Summary: - Choice B is incorrect because shortness of breath with amiodarone is not a common side effect to be reassured about. - Choice C is incorrect as monitoring symptoms at home may delay necessary medical intervention. - Choice D is incorrect as reducing physical activity does not address the potential serious side effect of amiodarone.

Correct Answer: D

Rationale: The correct answer is D: Notify the healthcare provider immediately. When a client on nitroglycerin reports chest pain, it could indicate a worsening condition or potential myocardial infarction. The nurse's priority is to notify the healthcare provider promptly for further assessment and intervention. Administering nitroglycerin (choice A) may not address the underlying cause of the chest pain. Administering morphine (choice B) may mask symptoms and delay appropriate treatment. Administering aspirin (choice C) is important in chest pain management but does not take priority over notifying the healthcare provider for further evaluation and guidance.

Correct Answer: A

Rationale: The correct answer is A: Cough. Enalapril is an ACE inhibitor that can cause a dry, persistent cough as a common side effect. It is important to monitor for this because it can indicate a potentially serious adverse reaction called angioedema. Hyperkalemia (B) is a possible side effect of enalapril but is typically not as urgent to monitor as cough. Hypotension (C) is a common side effect but is usually monitored during the initial dose titration. Dizziness (D) is a less common side effect and is often transient. Monitoring for cough is crucial to detect and manage any potential angioedema promptly.

Correct Answer: C

Rationale: The correct answer is C) Clear lung sounds and decreased heart rate. In heart failure, the heart's inability to pump effectively leads to fluid buildup in the lungs, causing crackles or wheezes on auscultation. Clear lung sounds indicate improved gas exchange and reduced pulmonary congestion, reflecting successful treatment. Decreased heart rate suggests that the heart is functioning more efficiently, reducing the workload on the heart. Option A, weight loss and diuresis, may occur with successful heart failure treatment due to fluid removal, but it does not directly indicate improved cardiac function. Option B, warm skin and less fatigue, are not specific indicators of heart failure treatment success but may be related to general well-being. Option D, absence of chest pain and improved level of consciousness (LOC), are important outcomes but do not directly reflect the effectiveness of heart failure treatment. Educationally, understanding these indicators is crucial for nurses caring for patients with heart failure. Monitoring lung sounds and heart rate helps assess treatment effectiveness, guiding interventions and optimizing patient outcomes. This question reinforces the importance of recognizing key clinical indicators of heart failure improvement.

Correct Answer: D

Rationale: In this scenario, the most important information to communicate to the physician regarding the use of fibrinolytic therapy with tPA for a patient with acute myocardial infarction is option D) The patient has had continuous chest pain since 1:00 PM. The correct answer is D because the duration of chest pain is a critical factor in determining the eligibility for fibrinolytic therapy. The time frame of symptom onset is crucial as fibrinolytic therapy is most effective when administered within a specific window period from the onset of symptoms. Option A is incorrect because a history of alteplase use 8 months ago does not impact the current decision-making process for acute management of AMI. Option B is not directly relevant to the decision to administer fibrinolytic therapy. Option C, T wave inversions on the ECG, while important for diagnosing AMI, are not as time-sensitive as the duration of chest pain in determining the need for immediate fibrinolytic therapy. Educationally, understanding the time-sensitive nature of interventions in acute conditions like AMI is crucial for healthcare providers. Timely communication of critical information to the healthcare team can significantly impact patient outcomes, making it essential for healthcare professionals to prioritize and convey relevant details accurately and promptly.