A nurse is admitting a client who reports chest pain.

Exhibits

The nurse is preparing the client for the cardiac catheterization. Which of the following actions should the nurse take? (Select all that apply.)

Obtain the client's vital signs.

Witness the client's signature on the Informed consent form.

Confirm the client's allergies.

inform the client of the risks of the procedure.

Mark the surgical site.

Answer and Explanation

Correct Answer : A,B,C

A. Obtain the client's vital signs: This is correct. Vital signs should be assessed to monitor the client's cardiovascular status before any invasive procedure, especially in the context of a myocardial infarction.
B. Witness the client's signature on the informed consent form: This is correct. The nurse should witness the client's signature on the informed consent form, ensuring that the client understands the procedure and consents to it.
C. Confirm the client's allergies: This is correct. Confirming allergies is crucial before any procedure to prevent allergic reactions to medications, contrast dye, or other substances used during the procedure.
D. Inform the client of the risks of the procedure: This is incorrect. It is the responsibility of the provider to explain the risks of the procedure in detail to the client. The nurse ensures that the client understands and that consent is given, but the nurse does not provide the detailed explanation of risks.
E. Mark the surgical site: This is incorrect. Marking the surgical site is typically done by the provider, not the nurse, and is required only if a surgical procedure is being performed, which is not the case for a cardiac catheterization.

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Correct Answer is A

Explanation

A. Obtaining an ECG is the appropriate action to assess for any changes in the heart's electrical activity that may indicate worsening ischemia or other complications, such as a myocardial infarction. Even though the pain has decreased, it is important to evaluate the underlying cause of the chest pain, particularly with unstable angina.
B. Initiating a peripheral IV is not the priority action unless the client requires immediate medication or fluids. In this case, the primary concern is assessing the cause of the chest pain through an ECG.
C. Administering another nitroglycerin tablet is not appropriate at this point. The client reports a significant reduction in pain (from 6 to 2), indicating that the first dose of nitroglycerin was effective. Administering additional doses without further assessment could be unnecessary and may lead to hypotension.
D. Calling the Rapid Response Team is not indicated at this point, as the client’s condition seems to be improving with the nitroglycerin. The priority action is to assess the client’s condition further with an ECG.

A. Perform passive range-of-motion exercises to the ankle. B. Elevate the ankle. C. Place a compression bandage on the ankle. D. Apply heat to the ankle. E. Encourage rest.

Correct Answer is ["B","C","E"]

Explanation

A. Passive range-of-motion exercises should be avoided in the acute phase of a sprain. Early movement can aggravate the injury and delay healing. Rest is crucial in the first 24-48 hours.
B. Elevating the ankle helps reduce swelling and promotes venous return, which is important for managing an acute sprain.
C. Applying a compression bandage helps control swelling and provides support to the injured area. It is important to ensure that the bandage is not too tight, as this can impair circulation.
D. Heat is generally not recommended in the acute phase of an injury, as it can increase swelling and inflammation. Ice is preferred in the first 24-48 hours to reduce inflammation and pain.
E. Encouraging rest is essential to allow the ankle to heal and prevent further injury. Movement or activity can exacerbate the sprain and prolong recovery.

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A nurse is admitting a client who reports chest pain. Exhibits The nurse is preparing the client for the cardiac catheterization. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is caring for a client who has an acute ankle sprain. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

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A nurse is admitting a client who reports chest pain.

Exhibits

The nurse is preparing the client for the cardiac catheterization. Which of the following actions should the nurse take? (Select all that apply.)