A nurse is assisting with the care of a client.
Complete the following sentence by using the list of options.
After notifying the provider, the nurse should first
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
- Administer sublingual nitroglycerin. Nitroglycerin is a first-line treatment for angina or suspected myocardial infarction. It dilates coronary arteries, improving blood flow and reducing myocardial oxygen demand.
- Apply supplemental oxygen. Routine oxygen administration is no longer recommended unless the client is hypoxic (oxygen saturation below 90%) because excessive oxygen can lead to vasoconstriction and worsen myocardial injury.
- Obtain a 12-lead ECG. While an ECG is important for diagnosing myocardial infarction, the priority in an acute chest pain episode is symptom relief and hemodynamic stability. The ECG should already have been obtained at admission.
- Administer morphine sulfate IV. Morphine is used to manage severe chest pain that is not relieved by nitroglycerin. It reduces myocardial oxygen demand, preload, and anxiety, which can help relieve symptoms.
- Monitor vital signs. Continuous monitoring is essential, but it is not the most immediate intervention in an acute episode of worsening chest pain. The focus should be on relieving ischemia and reducing myocardial workload.
- Educate the client about smoking cessation. While smoking cessation is critical for long-term cardiovascular health, education is not a priority when the client is experiencing acute chest pain requiring immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Alternate activity and rest. Clients with heart failure should balance activity and rest to prevent overexertion and minimize cardiac workload. Frequent rest periods help conserve energy and reduce symptoms such as dyspnea and fatigue.
B. Reduce sodium intake to 2 g per day. Limiting sodium intake helps prevent fluid retention and reduces the risk of worsening heart failure. Excess sodium contributes to increased blood volume and exacerbates symptoms such as edema and shortness of breath.
C. Consume a low-fiber diet. A low-fiber diet is not necessary for heart failure management. Adequate fiber intake is beneficial for preventing constipation, which can increase strain during bowel movements and lead to hemodynamic stress. A high-fiber diet is generally encouraged.
D. Gradually increase activity each day. Clients should slowly increase their activity level based on tolerance to improve cardiovascular function. Overexertion should be avoided, but regular, controlled exercise helps maintain mobility and enhance overall heart health.
E. Eat small, frequent meals each day. Eating smaller meals reduces gastric distension and minimizes pressure on the diaphragm, which can help alleviate shortness of breath. Large meals can increase metabolic demands and contribute to discomfort in clients with heart failure.
Correct Answer is B
Explanation
A. Discontinue this medication if this occurs again. Stopping a newly prescribed medication without consulting a provider is not recommended. Many medications, including antihypertensives, can cause lightheadedness, and adjustments or precautions should be discussed with a healthcare provider rather than discontinuing the drug independently.
B. Sit back down for a few minutes when this occurs. Lightheadedness upon standing is often due to orthostatic hypotension, which can be managed by sitting back down to allow blood pressure to stabilize. Slowly changing positions, staying hydrated, and rising gradually can also help minimize symptoms.
C. Restrict your daily fluid intake. Reducing fluid intake can worsen symptoms of orthostatic hypotension by decreasing blood volume, leading to further drops in blood pressure. Instead, maintaining adequate hydration is essential to support circulatory stability and prevent dizziness.
D. Take a daily potassium supplement. Unless there is a confirmed potassium deficiency, supplementation is unnecessary and could lead to hyperkalemia, especially if the client is on medications affecting potassium levels. Lightheadedness is more commonly related to blood pressure changes rather than potassium imbalances.
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