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 B
Explanation
A. Believes that his brother's death will be reversible. This response is more typical of preschool-aged children (ages 3 to 5), who often perceive death as temporary or reversible, similar to sleep or separation. School-age children, however, begin to understand the finality of death, though they may still struggle with its implications.
B. Believes his bad behavior is causing his brother's death. School-age children (ages 6 to 12) often engage in magical thinking and may believe that their actions, thoughts, or behaviors are responsible for events, including illness and death. They may feel guilt and self-blame, thinking that past misbehavior contributed to their sibling's condition. Providing reassurance and education about the medical causes of the illness can help alleviate these feelings.
C. Alienates himself from his peers. While social withdrawal can occur in grieving children, school-age children typically seek peer support and may use friendships as a coping mechanism. Alienation is more commonly seen in adolescents, who might isolate themselves due to difficulty expressing emotions or fear of burdening others.
D. Regresses to an earlier developmental level. Regression, such as bedwetting, clinging behavior, or baby talk, is more commonly seen in younger children, particularly toddlers and preschoolers, when they experience stress or grief. School-age children are more likely to express distress through guilt, sadness, or behavioral changes rather than regression.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A,C"}}
Explanation
- Urticaria: Present in latex allergy, as hypersensitivity reactions to latex can cause pruritic hives due to histamine release.
- Hypercapnia: Present in malignant hyperthermia, as it results from uncontrolled skeletal muscle contractions leading to excessive carbon dioxide production.
- Wheezes: Present in latex allergy due to bronchoconstriction and airway hypersensitivity, which can lead to respiratory distress.
- Muscle rigidity: Present in malignant hyperthermia, as sustained muscle contractions occur due to excessive calcium release in skeletal muscles.
- Tachycardia: Present in both malignant hyperthermia and hypovolemic shock. Malignant hyperthermia causes tachycardia due to increased metabolic activity and hypercapnia, while hypovolemic shock results in tachycardia as a compensatory mechanism for reduced circulating volume.
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