A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema.

Secure client consent for coronary angiography and percutaneous coronary intervention.

Administer four 81 mg aspirin tablets providing instructions to chew before swallowing.

Place an indwelling urinary catheter and institute strict intake and output measurements.

Answer and Explanation

The Correct Answer is C

Given the client's symptoms of constant chest pressure that is unrelieved with rest, along with the client's appearance of anxiety, pallor, and diaphoresis, it indicates a high likelihood of an acute coronary event, such as a myocardial infarction (heart attack). In this situation, the nurse should prioritize immediate actions that address the potential cardiac emergency.

Aspirin is an essential medication in the initial management of acute coronary syndrome, including unstable angina and myocardial infarction. It helps to inhibit platelet aggregation and reduce the risk of clot formation in the coronary arteries. The chewable form of aspirin is recommended because it allows for more rapid absorption.

While evaluating extremities for perfusion, pulse volume, and pitting edema is important in assessing the client's overall cardiovascular status, it is not the immediate next step when faced with a suspected acute coronary event.

Securing client consent for coronary angiography and percutaneous coronary intervention (PCI) is a relevant step in the management of unstable angina and myocardial infarction, but it is not the immediate action to be taken in the emergency department. The client requires stabilization and initial medical interventions before procedural consent can be obtained.

Placing an indwelling urinary catheter and instituting strict intake and output measurements is not a priority action in this situation. The focus should be on addressing the potential acute coronary event and ensuring the client's cardiac stability. Urinary catheterization and monitoring of intake and output can be considered later, if necessary.

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Correct Answer is ["A","D"]

Explanation

Choice A rationale: Hypoxic-ischemic injury from submersion can lead to delayed cerebral edema. Monitoring is critical as the brain's inflammatory response to the initial insult often peaks several hours after the event.

Choice B rationale: Asphyxia is the initial event that occurred in the pool. By the time the child is admitted to the pediatric floor, the asphyxiation event has passed; the nurse now monitors for its aftereffects.

Choice C rationale: Near-drowning victims are more likely to experience hypotension due to myocardial depression or shifting fluid balances. Hypertension is not a typical expected complication in the immediate post-submersion recovery period.

Choice D rationale: Aspiration of water interferes with surfactant production and damages alveolar membranes, leading to pulmonary edema or ARDS. Respiratory status can deteriorate rapidly 6 to 8 hours after the initial insult.

Choice E rationale: The child was in cool water with an outdoor temperature of 64°F, making hypothermia the primary concern. Hyperthermia is not expected unless a secondary infection or a thermregulation failure occurs much later.

Choice F rationale: The head CT scan was negative for bleeding. Without a significant traumatic impact or pre-existing condition, a subdural hemorrhage is not a standard complication resulting from a submersion injury.

A. Multivitamins are contraindicated during treatment with weight-control medications such as orlistat. B. As a nutritional supplement, orlistat already contains all the recommended daily vitamins and minerals. C. Be sure to take the multivitamin and the medication at least two hours apart for best absorption and effectiveness. D. Following a well-balanced diet is a much healthier approach to good nutrition than depending on a multivitamin.

Correct Answer is C

Explanation

Orlistat is a weight-control medication that works by inhibiting the absorption of dietary

fats in the intestines. It can also interfere with the absorption of fat-soluble vitamins (such as vitamins A, D, E, and K) and beta-carotene. Therefore, it is important for the client to take a multivitamin supplement to ensure an adequate intake of these essential nutrients.

However, it is recommended to take the multivitamin and orlistat at least two hours apart. This is because orlistat can potentially interfere with the absorption of the

fat-soluble vitamins in the multivitamin if taken simultaneously. By spacing them apart, the client can optimize the absorption of both the medication and the multivitamin.

Multivitamins are not contraindicated during treatment with orlistat. In fact, they are often recommended to compensate for potential nutrient deficiencies.

While orlistat may contain some vitamins and minerals, it does not provide all the recommended daily amounts. Therefore, additional supplementation may be necessary. While following a well-balanced diet is indeed important for good nutrition, it does not address the need for specific nutrient supplementation when taking orlistat. Both a balanced diet and appropriate vitamin supplementation can be beneficial in this situation.

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A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","D"]

Explanation

A client has received a prescription for orlistat for weight and nutrition management. In addition to the medication, the client plans to take a multivitamin. Which teaching should the nurse provide?

Correct Answer is C

Explanation

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