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
Explanation
A. The client reports pain is reduced when he is positioned on his side. This information is relevant to the client's current condition and care plan. Pain management is a critical aspect of nursing care, and informing the oncoming nurse about the client’s preferred position for pain relief ensures continuity of care and appropriate interventions.
B. The client's partner visited earlier today for 2 hours. While social interactions are important for the client’s well-being, this information is not essential for a shift report unless it directly affects the client's condition or care needs.
C. The client's mother died 4 years ago from breast cancer. While family history can be relevant for long-term medical planning, it is not pertinent to the immediate shift report, which should focus on the client's current status and care needs.
D. The client received the prescribed antibiotic every 8 hours. While medication administration is important, the oncoming nurse can verify this information in the medication administration record (MAR). Shift reports typically focus on changes in condition, ongoing concerns, and necessary interventions rather than routine medication schedules.
Correct Answer is B
Explanation
A. Bradycardia is not a common adverse effect of levodopa-carbidopa. Instead, it may sometimes cause tachycardia (increased heart rate) in some patients. Monitoring for cardiovascular changes is essential, but bradycardia is not typically associated with this medication.
B. Hypotension is a documented adverse effect of levodopa-carbidopa. This medication can cause orthostatic hypotension, which is a drop in blood pressure when standing up, leading to dizziness or fainting. This finding should be carefully monitored and documented, as it can increase the risk of falls.
C. Constricted pupils are not typically an adverse effect of levodopa-carbidopa. Instead, this medication may cause dilated pupils (mydriasis) as a result of its effects on the autonomic nervous system, particularly if the patient is taking other medications that can affect pupil size.
D. Urinary frequency can occur with levodopa-carbidopa; however, it is not commonly classified as a significant adverse effect. While changes in urinary habits can happen, they are more often related to Parkinson's disease itself rather than the medication specifically. Therefore, urinary frequency should be monitored but is not a primary concern compared to hypotension.
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