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A nurse is assisting with the care of a client.

Exhibits

Complete the following sentence by using the list of options.

After notifying the provider, the nurse should first

and then
Answer and Explanation

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.


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Related Questions

Correct Answer is B

Explanation

A. Confusion can occur with electrolyte imbalances, including hyperkalemia, but it is not the most common or specific symptom associated with elevated potassium levels. More typical symptoms are related to muscle and gastrointestinal function.
B. Abdominal cramps are a common finding in clients with hyperkalemia (potassium level of 5.8 mEq/L). Elevated potassium can lead to increased gastrointestinal motility and irritability, resulting in symptoms such as abdominal cramps and diarrhea.
C. Positive Chvostek's sign indicates hypocalcemia (low calcium levels) and is not associated with hyperkalemia. This sign reflects increased neuromuscular excitability due to low calcium levels, so it would not be expected in this scenario.
D. Decreased bowel motility is typically associated with hypokalemia (low potassium levels) rather than hyperkalemia. Elevated potassium levels can cause increased bowel motility and may lead to gastrointestinal symptoms like diarrhea and cramping. Therefore, decreased bowel motility would not be an expected finding in this case.

Correct Answer is B

Explanation

A. "I will bathe my baby under a faucet of running water." Bathing a newborn under a running faucet increases the risk of accidental injury, sudden temperature changes, and loss of control while handling the baby. Instead, a gentle sponge bath or bathing in a small tub with controlled water temperature is recommended.
B. "I will wash my baby's face with a warm, wet washcloth without soap." This is an appropriate practice for newborn care. Using only warm water without soap helps prevent skin irritation, as a newborn’s skin is sensitive and prone to dryness. Special attention should be given to cleaning the eyes, nose, and mouth area gently.
C. "I will give my baby a bath every day." Daily bathing is not necessary for newborns and can lead to skin dryness and irritation. Instead, bathing two to three times per week is sufficient, with daily cleaning of the diaper area, face, and hands as needed.
D. "I will wash my baby's head using a moist towelette." While cleaning the baby’s head is important, a moist towelette is not the best method. The scalp should be gently washed with warm water and a mild baby shampoo to prevent buildup of oils and potential conditions like cradle cap.

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