A nurse is caring for a 65-year-old male client in the emergency department. The client is presenting with symptoms of a potential cardiac event and has been admitted for further evaluation.
Complete the following sentence by selecting the most appropriate actions based on the client’s current status.
The nurse should first
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
The nurse should first: Response 1: Notify the primary health care provider immediately.
This is crucial because the client is showing signs of a potential cardiac event, which requires immediate medical attention.
Then, the nurse should: Response 2: Start an IV line for potential medication administration.
Starting an IV line ensures that the client can receive any necessary medications quickly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
He appears anxious about the transfer provides subjective information about the client's emotional state. While important, it's not essential for the transfer report which typically focuses on objective, actionable data.
Choice B rationale
His partner has been visiting is valuable for understanding the client's support system, but it does not directly affect the client's clinical care during transfer.
Choice C rationale
He is voiding adequately offers relevant information about the client's bodily function, important for ongoing care but not as critical as allergy information.
Choice D rationale
He is allergic to sulfa provides essential medical information that can affect the client's treatment plan. Knowing allergies is crucial to prevent adverse reactions to medications.
Correct Answer is ["A","B"]
Explanation
Choice A rationale: It is important for the client to complete the full course of antibiotics to ensure the infection is fully treated and to prevent antibiotic resistance.
Choice B rationale: Keeping the oxygen delivery system at least 8 feet from any heat source is crucial for safety to prevent the risk of fire.
Choice C rationale: Decreasing the steroid dose each day is not relevant in this case since there is no mention of the client being on steroids for the pneumonia treatment.
Choice D rationale: While taking antibiotic medication with or without food can be important, the specific instruction for this medication should be based on the pharmacist's or provider's recommendation. However, this option is not the best answer compared to completing the full course of antibiotics.
Choice E rationale: Adjusting the oxygen flow rate as needed to ease breathing should only be done under medical supervision. Clients are typically instructed to use a prescribed oxygen flow rate, and adjustments should not be made without consulting a healthcare provider.
Choice F rationale: Taking steroid medication in the morning can help reduce side effects, but again, this option is not relevant since the client's current treatment does not include steroids.
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