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.
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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 D
Explanation
Choice A rationale
Encouraging a partner to eat three large meals each day may not be appropriate in end-of-life care. Clients often have reduced appetite, and small, frequent meals are usually recommended to avoid overwhelming them.
Choice B rationale
Opioids are commonly used in end-of-life care to manage pain and distress. Even if respiratory distress occurs, opioids are not typically restricted, but rather adjusted to balance pain relief and respiratory function.
Choice C rationale
Using an electric blanket can pose safety risks, including burns or electrical hazards, especially if the client is unable to communicate discomfort. Instead, alternative methods such as warm blankets are safer.
Choice D rationale
Assuming the partner can hear even if they do not respond is important. Hearing is believed to be one of the last senses to fade, and speaking to the client can provide comfort and connection.
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