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A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse?

P wave touching the T wave

Midsternal chest pain

Increased urine output

Mild orthostatic hypotension

Answer and Explanation

The Correct Answer is B

A. P wave touching the T wave can indicate an issue but is less urgent than chest pain.

B. Midsternal chest pain could indicate myocardial ischemia or infarction, requiring immediate intervention.

C. Increased urine output is not an urgent concern in this context.

D. Mild orthostatic hypotension is not as urgent as chest pain.

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Correct Answer is B

Explanation

A. Sucking on small quantities of ice chips is not appropriate in this case as it may worsen the airway obstruction or cause further irritation.

B. Applying oxygen and continuously monitoring the client's pulse oximetry will help ensure that the client's oxygen saturation remains adequate and that they do not experience respiratory distress or hypoxemia due to inhalation injury. Early intervention is crucial to prevent worsening of respiratory status.

C. Humidified room air can help in cases of airway irritation, but the priority is to ensure oxygenation and avoid hypoxia.

D. Antitussive medications may be indicated later, but airway management and oxygenation take precedence.

A. magnetic resonance imaging (MRI) B. uroflowmetry studies C. cystourethroscopy D. transrectal ultrasonography (TRUS)

Correct Answer is D

Explanation

A. Magnetic resonance imaging (MRI) may be used in some cases, but TRUS is more commonly used to guide biopsies after concerns arise from DRE or PSA findings.

B. Uroflowmetry studies measure urine flow, which is not the primary concern in evaluating an enlarged prostate related to potential cancer.

C. Cystourethroscopy is used to evaluate the bladder or urethra and is not typically needed in the assessment of an enlarged prostate.

D. Transrectal ultrasonography (TRUS) is commonly used in the evaluation of prostate abnormalities, especially when there are concerns about prostate cancer due to an abnormal DRE or elevated PSA. It helps in visualizing the prostate and guiding biopsy.

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A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse?

Nursing Test Bank

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