A nurse is caring for a 58-year-old male client in the emergency department (ED) who presents with an irregular pulse and elevated blood pressure.

Exhibits

The nurse is planning care for the client. For each potential prescription, indicate whether it is indicated, nonessential, or contraindicated.

Administer O2 to maintain oxygen saturation greater than 90%.

Prepare the client for intubation.

Apply continuous ECG monitoring.

Obtain the client’s family history.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"}}

Rationales:

Administer O2 to maintain oxygen saturation greater than 90%: This prescription is indicated. Hypoxia can exacerbate cardiac and respiratory issues, so it is essential to maintain adequate oxygen levels in the blood. Supplemental oxygen can help improve tissue oxygenation and reduce strain on the heart.
Apply continuous ECG monitoring: This prescription is indicated. Continuous ECG monitoring is crucial in detecting arrhythmias and ischemic changes in a patient with cardiac symptoms and irregular pulse. Early detection allows for timely intervention and management of potentially life-threatening cardiac events.
Obtain the client’s family history: This prescription is nonessential. While obtaining a family history is useful for identifying potential genetic predispositions to cardiac and metabolic conditions, it is not immediately necessary for the acute management of the client’s current symptoms.
Prepare the client for intubation: This prescription is contraindicated. The client is currently maintaining an adequate respiratory rate and oxygen saturation on room air. There is no indication of respiratory failure or inability to maintain airway patency. Intubation would be an unnecessarily invasive procedure at this time.

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Correct Answer is A

Explanation

Choice A rationale

Nitroglycerin causes vasodilation, leading to headaches as a common adverse effect. These headaches are due to the increased blood flow and dilation of cerebral blood vessels.

Choice B rationale

Headaches do not indicate tolerance to nitroglycerin. Tolerance typically presents with a diminished therapeutic effect, not adverse effects like headaches.

Choice C rationale

Anxiety-induced headaches are unlikely since nitroglycerin-induced headaches are a physiological response to vasodilation, not psychological factors.

Choice D rationale

An allergic reaction to nitroglycerin would present with symptoms like rash or itching, not headaches. Headaches are a known and expected adverse effect.

A. Intermittent claudication. B. Rest pain. C. Foot ulcers. D. Dependent rubor.

Correct Answer is A

Explanation

Choice A rationale

Intermittent claudication, characterized by muscle pain during exercise relieved by rest, indicates early-stage peripheral arterial disease due to decreased blood flow. It is an early symptom resulting from insufficient oxygen supply to muscles.

Choice B rationale

Rest pain occurs in more advanced peripheral arterial disease and indicates critical limb ischemia. It is a late-stage symptom, usually present even at rest due to severely compromised blood flow.

Choice C rationale

Foot ulcers are signs of advanced peripheral arterial disease, often developing due to poor circulation and delayed wound healing. These ulcers indicate severe disease progression and significant arterial insufficiency.

Choice D rationale

Dependent rubor, a red discoloration of the skin when the leg is lowered, occurs in advanced peripheral arterial disease. It results from chronic ischemia and dilatation of the small blood vessels in response to prolonged tissue hypoxia.

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A nurse is caring for a 58-year-old male client in the emergency department (ED) who presents with an irregular pulse and elevated blood pressure. Exhibits The nurse is planning care for the client. For each potential prescription, indicate whether it is indicated, nonessential, or contraindicated.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain.The client reports relief from the chest pain but now he is experiencing a headache.Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a client who has peripheral arterial disease (PAD). Which of the following symptoms should the nurse expect to find in the early stage of the disease?

Correct Answer is A

Explanation

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