A nurse is assisting with the care of a client.
Complete the following sentence.
After notifying the provider, the nurse should first
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
The client's symptoms are concerning for angina or a possible myocardial infarction (heart atack) and require immediate intervention. Nitroglycerin is a medication that can help relieve chest pain associated with cardiac events by dilating blood vessels and reducing the workload on the heart.
Therefore, the nurse should administer nitroglycerin as ordered by the provider. After administering nitroglycerin, the nurse should obtain an ECG to assess for any changes in cardiac rhythm or evidence of ischemia (lack of blood flow to the heart muscle).
The ECG can provide important diagnostic information and guide further treatment decisions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Irrigation of a wound with antibiotic solution is incorrect. Typically, irrigation of a wound with antibiotic solution doesn't require informed consent unless there are specific factors or risks involved that require it. This is usually considered a routine wound care procedure.
Choice B Reason:
Administration of an iron injection using Z-track technique is incorrect. Informed consent may not be required for this procedure if it's a routine and commonly performed nursing intervention. However, if there are specific concerns or potential risks (e.g., allergy to the medication), informed consent might be necessary.
Choice C Reason:
Insertion of a nasogastric tube is correct. Insertion of a nasogastric tube generally requires informed consent, especially if it's a non-emergent procedure. Informed consent is essential because there can be risks associated with the insertion, and the client should be informed and agree to it.
Choice D Reason:
Placement of a central venous catheter is correct. Placement of a central venous catheter definitely requires informed consent. It's a more invasive procedure that involves entering a major blood vessel, and there are specific risks and potential complications associated with it.
Correct Answer is D
Explanation
Choice A Reason:
Chloasma is incorrect. Chloasma, also known as the "mask of pregnancy," refers to the brownish or tan patches of pigmentation that can appear on the face during pregnancy. It is not related to the purplish discoloration of the cervix, vagina, and vulva described in the scenario.
Choice B Reason:
Hegar's sign is incorrect. Hegar's sign is a softening and compressibility of the lower uterine segment (the area between the cervix and the body of the uterus) that can be felt during a pelvic examination. It is not related to discoloration of the genital area.
Choice C Reason:
Ballottement is incorrect. Ballottement is a technique used during a pelvic examination to assess the fetus's position and is characterized by the examiner feeling a rebound movement of the fetus when it is pushed and then released. It does not involve discoloration of the genital area.
Choice D Reason:
Chadwick's sign is a bluish-purple or purplish discoloration of the cervix, vagina, and vulva that can occur during pregnancy. This discoloration is due to increased blood flow to the pelvic area and is considered a normal physiological change during pregnancy. It is one of the early signs of pregnancy and can be observed as early as the sixth week of gestation. It is named after the American obstetrician James Read Chadwick, who first described it.
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