A nurse is assisting with the care of a client.
Complete the following sentence.
After notifying the provider, the nurse should first and then . (Separate your answers with a comma ',')
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
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 A
Explanation
This statement should be included in the change-of-shift report because it provides vital information about the patient’s condition and any changes that have occurred to the patient during the shift.
Statement B is wrong because it does not provide relevant information about the patient’s current condition or changes that have occurred during the shift. Statement C is wrong because it does not provide relevant information about the patient’s medical condition. Statement D is wrong because it does not provide new information about changes that have occurred during the shift.
Change-of-shift reports are key to inpatient care because they provide vital information about and responsibility for the patient from the off-going provider to the on-coming provider.
Correct Answer is C
Explanation
A.While monitoring the client's physical condition, including range of motion, is important, it typically needs to be done more frequently than every 60 minutes. The Joint Commission and other regulatory bodies often recommend continuous observation and checks every 15 minutes.
B.Typically, a provider's order for restraints must be obtained immediately or within a very short time frame (often within an hour), not 48 hours. Regulations vary but generally require prompt notification and authorization.
C.Restraints should only be used as a last resort and for the shortest duration possible. The goal is to ensure the client's safety and the safety of others while minimizing the use of restraints. Removing the restraints as soon as the client is calm and no longer a threat to themselves or others is essential to respecting the client's rights and promoting their dignity.
D.Offer the client a nutritious snack every 4 hr.: While providing nutrition and hydration is important, the primary focus immediately after applying restraints should be on the client's safety and the frequent assessment of their condition. Offering a snack every 4 hours is not the immediate priority in this context.
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