The patient develops a low-grade fever 18 hours post-operatively and has diminished breath sounds. Which of the following actions is most appropriate for the nurse to take to prevent complications? i.Administer antibiotics iv.Decrease fluid intake ii.Encourage coughing and deepbreathing v.Ambulate patient as ordered iii.Administer acetaminophen (Tylenol)

Correct Answer: A

Rationale: In this scenario, the patient developing a low-grade fever post-operatively along with diminished breath sounds could indicate the possibility of atelectasis or pneumonia. The most appropriate actions for the nurse to take to prevent complications in this situation would be to encourage coughing and deep breathing (to help clear secretions and improve lung expansion) and ambulate the patient as ordered (to promote lung ventilation and prevent further complications). Administering antibiotics, acetaminophen for fever management, and decreasing fluid intake may be considered based on the healthcare provider's assessment and orders, but the immediate nursing interventions to address the presenting symptoms are encouraging coughing and deep breathing and ambulating the patient.

Correct Answer: B

Rationale: Isolated systolic hypertension is characterized by elevated systolic blood pressure (SBP) with normal diastolic blood pressure (DBP). In this case, if the systolic BP is elevated and the diastolic BP is normal, the nurse would recognize this pattern as indicative of isolated systolic hypertension. This condition is more common in older adults and is associated with aging and stiffening of the arteries. Patients with isolated systolic hypertension are at an increased risk of cardiovascular events, so it is important to monitor and manage their blood pressure appropriately.

Correct Answer: B

Rationale: Angiotensin converting enzyme (ACE) inhibitors are commonly used to manage hypertension and heart failure by blocking the conversion of angiotensin I to angiotensin II. In clients with renal or hepatic impairment, as well as in older adults, the metabolism and excretion of ACE inhibitors may be altered, leading to an increased risk of drug accumulation and potential hypotension. Monitoring these clients cautiously for a sudden drop in blood pressure, especially during the first 1-3 hours after the initial dose, is crucial to prevent complications such as dizziness, lightheadedness, and falls. Adjustments in dosage or frequency may be necessary to ensure the safe and effective use of ACE inhibitors in these populations.

Correct Answer: A

Rationale: Clients who take warfarin (Coumadin) should refrain from foods such as green leafy vegetables and soybeans because these foods contain high levels of Vitamin K. Vitamin K plays a crucial role in blood clotting, which may counteract the anti-coagulant effects of warfarin. Therefore, consuming large amounts of Vitamin K-rich foods can reduce the effectiveness of warfarin in preventing blood clots, leading to potential health risks. It is important for clients on warfarin therapy to maintain a consistent intake of Vitamin K in their diet to ensure the medication works effectively.

Correct Answer: A

Rationale: The sympathetic nervous system is responsible for our "fight or flight" response to stressful situations. Norepinephrine is the primary neurotransmitter that mediates the sympathetic response, acting on adrenergic receptors in various target tissues. It helps to increase heart rate, elevate blood pressure, dilate air passages in the lungs, and mobilize energy stores in the body to prepare for physical exertion or stress. Acetylcholine is another neurotransmitter involved in the sympathetic nervous system, but norepinephrine is the primary mediator of the fight or flight response.