A client arrives to the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?
Aspirin.
Nitroglycerin.
Morphine.
Heparin.
The Correct Answer is B
Rationale
A. Aspirin is commonly used in the emergency setting for chest pain suspected to be due to acute coronary syndrome (ACS), which includes conditions like myocardial infarction (heart attack). It works by reducing blood clotting and can help alleviate symptoms in some cases. It is typically safe to administer aspirin
B. Sildenafil can interact with nitrates, such as nitroglycerin, and result in a significant drop in blood pressure. Therefore, the nurse should withhold nitroglycerin to prevent potential adverse effects.
C. Morphine is a potent opioid pain medication used in the emergency department for severe pain relief, including chest pain associated with suspected myocardial infarction. It can help reduce pain and anxiety in acute coronary syndromes. It has no significant interaction with sildenafil.
D. Heparin is an anticoagulant medication used to prevent blood clotting. It is often administered in the hospital setting for various indications, such as deep vein thrombosis, pulmonary embolism, or in some cases of acute coronary syndromes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale
A. While it is important background information, it is not directly relevant to the acute change in the client's condition (increasing confusion and agitation). Therefore, this should not be provided first in the SBAR communication.
B. Knowing the client's current medications is important for understanding any potential causes or exacerbating factors related to the sudden onset of confusion and agitation. However, this is also background information and does not immediately address the acute change in the client's condition.
C. This is the most critical piece of information to provide first in the SBAR communication. Sudden onset of increasing confusion and agitation can indicate various urgent issues such as delirium, infection, metabolic disturbances, or neurological complications. This requires immediate attention and intervention from the healthcare provider.
D. While knowing the client's healthcare power of attorney is important for ensuring appropriate decision-making if needed, it is not urgent information in the context of reporting a sudden change in the client's condition. This can be discussed later in the SBAR communication or as part of the background information if relevant to the client's care.
Correct Answer is D
Explanation
Rationale
A. Wearing a face mask is a standard precaution to protect against airborne or droplet transmission of pathogens. However, MRSA is primarily transmitted through direct contact with infected wounds or contaminated surfaces rather than through the air.
B. Contact precautions are essential for preventing the spread of MRSA. These precautions include wearing gloves and gowns when in direct contact with the client or potentially contaminated surfaces. However, this is not of immediate concern.
C. Monitoring the white blood cell count (WBC) is crucial in assessing for signs of infection, including wound infections. An increase in WBC count can indicate systemic infection or local wound infection, which might be related to MRSA. Early detection and prompt reporting allow for timely intervention, such as initiating appropriate antibiotic therapy or further wound assessment.
D. This is because maintaining a clean environment around the wound is crucial to prevent infection
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