Hide definitions
A client who is uses ipratropium reports having nausea, blurred vision, headaches, and insomnia after
using the inhaler. Which action should the registered nurse (RN) implement first?
Withhold medication and report symptoms and vital signs to healthcare provider.
Give PRN medication for nausea and vomiting and evaluate client in 30 minutes.
Reassure client that the ipratropium given will alleviate the symptoms.
Delay administration of ipratropium until next maintenance medication is scheduled.
Withhold medication and report symptoms and vital signs to healthcare provider.
**Again think beneficial to the patient overall as a primary concern
Rationale
Headache, nausea, blurred vision and insomnia are symptoms of excessive use of ipratropium, so
withholding the medication until the healthcare provider is notified should be initiated to maintain client
safety.
,A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted for evaluation for Acute
Coronary Syndrome (ACS). Which cardiac biomarker should the registered nurse (RN) anticipate to be
elevated if the client experienced myocardial damage?
Creatine Kinase (CK-MB).
Serum troponin.
Myoglobin.
Ischemia modified albumin.
Serum troponin. - is a lab that must always be requested because it is indicative of heart muscle
damage.
Rationale
Troponin is the most sensitive and specific test for myocardial damage. Troponin elevation is more
specific than CK-MB.
, A client with cirrhosis of the liver asks the registered nurse (RN) to explain how varicose veins can occur
in the esophagus. Which statement should the RN provide to teach the client about the physiological
etiology?
The enlarged liver presses on the lower half of the esophagus which weakens blood vessel walls.
Abnormal vessels form as a result of liver damage that causes chronic low serum protein levels.
Esophageal swelling and tissue damage causes blood to circulate blood back through the stomach.
Increased portal pressure causes blood flow through liver to be shunted to the esophageal vessels.
Increased portal pressure causes blood flow through liver to be shunted to the esophageal vessels.
Rationale
Cirrhotic and fibrosed liver damage causes obstructed blood flow through portal vessels to the liver
which increases the portal pressurecausing the blood flow through the liver to be shunted to the
esophageal vessels. The result of this shunting of blood causes the esophageal vessels (veins) to
balloon out and weaken. As the portal hypertension increases, these esophageal varices can rupture
and cause bleeding resulting in bloody emesis and black tarry stools.
A client who is uses ipratropium reports having nausea, blurred vision, headaches, and insomnia after
using the inhaler. Which action should the registered nurse (RN) implement first?
Withhold medication and report symptoms and vital signs to healthcare provider.
Give PRN medication for nausea and vomiting and evaluate client in 30 minutes.
Reassure client that the ipratropium given will alleviate the symptoms.
Delay administration of ipratropium until next maintenance medication is scheduled.
Withhold medication and report symptoms and vital signs to healthcare provider.
**Again think beneficial to the patient overall as a primary concern
Rationale
Headache, nausea, blurred vision and insomnia are symptoms of excessive use of ipratropium, so
withholding the medication until the healthcare provider is notified should be initiated to maintain client
safety.
,A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted for evaluation for Acute
Coronary Syndrome (ACS). Which cardiac biomarker should the registered nurse (RN) anticipate to be
elevated if the client experienced myocardial damage?
Creatine Kinase (CK-MB).
Serum troponin.
Myoglobin.
Ischemia modified albumin.
Serum troponin. - is a lab that must always be requested because it is indicative of heart muscle
damage.
Rationale
Troponin is the most sensitive and specific test for myocardial damage. Troponin elevation is more
specific than CK-MB.
, A client with cirrhosis of the liver asks the registered nurse (RN) to explain how varicose veins can occur
in the esophagus. Which statement should the RN provide to teach the client about the physiological
etiology?
The enlarged liver presses on the lower half of the esophagus which weakens blood vessel walls.
Abnormal vessels form as a result of liver damage that causes chronic low serum protein levels.
Esophageal swelling and tissue damage causes blood to circulate blood back through the stomach.
Increased portal pressure causes blood flow through liver to be shunted to the esophageal vessels.
Increased portal pressure causes blood flow through liver to be shunted to the esophageal vessels.
Rationale
Cirrhotic and fibrosed liver damage causes obstructed blood flow through portal vessels to the liver
which increases the portal pressurecausing the blood flow through the liver to be shunted to the
esophageal vessels. The result of this shunting of blood causes the esophageal vessels (veins) to
balloon out and weaken. As the portal hypertension increases, these esophageal varices can rupture
and cause bleeding resulting in bloody emesis and black tarry stools.
