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A nurse is assisting with the care of a client.

Complete the following sentence by using the lists of options.

After notifying the provider, the nurse should first

and then

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

  • request a prescription for an increase in statin medication: Although the client's total cholesterol is elevated at 230 mg/dL, adjusting lipid management is not the immediate priority during an acute chest pain episode. The immediate focus should be stabilizing airway, breathing, and circulation.
  • prepare the client for cardiac catheterization: Cardiac catheterization may ultimately be needed to assess coronary artery blockages, but before this, the client must be stabilized with oxygen and medications to control chest pain and improve oxygenation.
  • administer oxygen at 2 L/min via nasal cannula: The client’s oxygen saturation dropped to 92% on room air, which is low for someone experiencing chest pain and possible myocardial ischemia. Administering supplemental oxygen improves myocardial oxygen supply and reduces cardiac workload, addressing airway and breathing priorities.
  • check a STAT cardiac troponin: The client’s initial troponin level was normal, but troponin can take several hours to rise after myocardial injury. While monitoring serial troponins is important, managing oxygenation and chest pain relief takes precedence right now.
  • administer sublingual nitroglycerin: After ensuring oxygenation, sublingual nitroglycerin should be administered to relieve chest pain by dilating coronary arteries and decreasing myocardial oxygen demand. It helps reduce ischemia and may prevent further cardiac injury.
  • request a prescription for a beta-blocker: Beta-blockers help control heart rate and blood pressure but are not the immediate first-line response for active chest pain and oxygen desaturation. Oxygen and nitroglycerin must be prioritized first to address the acute ischemic event.


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Related Questions

Correct Answer is A

Explanation

A. A client who developed a pressure ulcer on the sacrum: The development of a pressure ulcer during hospitalization is considered a preventable adverse event and requires an incident report. It reflects a potential lapse in standard care practices related to skin integrity and client repositioning.

B. A client who refused to take a prescribed stool softener: Clients have the right to refuse medications. This occurrence should be documented in the medical record, but it does not require an incident report since it is an exercise of client autonomy.

C. A client who reported feeling dizzy while ambulating: Feeling dizzy during ambulation should be documented and addressed with safety measures, but if no fall or injury occurred, it typically does not necessitate a formal incident report.

D. A client who received medication 1 hr after it was due: A slight delay in medication administration may need to be documented depending on the medication's importance, but a 1-hour delay, unless involving critical medication like insulin or anticoagulants, usually does not require a formal incident report.

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

Explanation

  • "Use sunglasses if your eyes are sensitive to light.": After thyroid surgery, especially if the client has Graves’ disease and associated exophthalmos, the eyes may remain sensitive to light. Wearing sunglasses helps protect the eyes from irritation and prevents further discomfort while healing progresses.
  • "Continue eating foods with protein.": Maintaining adequate protein intake is important for healing after surgery. Protein supports tissue repair, immune function, and recovery, making it an essential part of the client’s postoperative nutrition plan.
  • "Remain on bedrest for 3 to 5 days following discharge.": Prolonged bedrest after thyroid surgery is not recommended. Early ambulation helps prevent complications such as blood clots and promotes recovery. Clients are usually encouraged to resume light activities shortly after surgery.
  • "You need to support your neck when coughing or moving.": After thyroidectomy, supporting the neck when coughing, sneezing, or repositioning helps protect the surgical site, reduces strain on the incision, and minimizes discomfort, promoting safer healing.
  • "You will no longer need to take any medications for your thyroid now that you have had surgery.": This is incorrect because many clients require lifelong thyroid hormone replacement therapy after a thyroidectomy to maintain normal metabolic function, depending on how much thyroid tissue was removed.

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