A nurse is caring for 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":"B","dropdown-group-2":"B"}
After notifying the provider, the nurse should first administer oxygen at 2 L/min via nasal cannula and then administer sublingual nitroglycerin
Rationale
Administer oxygen at 2 L/min via nasal cannula
The client is experiencing shortness of breath and chest pain with a decrease in oxygen saturation (92%), which is a concern, indicating that the client may be experiencing an acute cardiovascular event such as a myocardial infarction (MI). Administering oxygen helps to increase the oxygen supply to the heart and other vital organs.
Administer sublingual nitroglycerin
Nitroglycerin is a vasodilator that can help relieve chest pain associated with conditions like angina or myocardial infarction by increasing blood flow to the heart and reducing myocardial oxygen demand. The client’s pain level has increased to 7/10 on the pain scale, which suggests the chest pain may be related to an acute cardiac event.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Restraints should never be attached to the side rails, as this can increase the risk of injury.
B. The client's condition should be documented every 15 minutes to ensure their safety and comfort while in restraints.
C. A PRN prescription for restraints is not appropriate; restraints should be used only as a last resort and with a physician's order.
D. The restraint should be removed at least every 2 hours to assess for skin integrity and allow for range- of-motion exercises.
Correct Answer is D
Explanation
A. Inserting a pillow under the knees can lead to pressure on the lower abdomen, potentially compromising blood flow.
B. The lithotomy position may not be appropriate for placental blood flow.
C. Reverse Trendelenburg may increase blood pressure and affect placental perfusion.
D. Placing a wedge under the client's hip is a common technique to prevent supine hypotension syndrome, which could compromise placental blood flow.
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