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A nurse is caring for a client in the emergency department (ED).

<div id="exhibits">Exhibits</div>

The nurse is planning care for the client. For each potential prescription, indicate whether it is an anticipated (high priority), nonessential (low priority), contraindicated(unrelated).

Select one or more in each option.

A.

Administer furosemide IV

B.

Prepare the client for intubation

C.

Obtain the client’s full family history

D.

Administer O2 to maintain oxygen saturation greater than 90%

E.

Apply continuous ECG monitoring

F.

Obtain vascular access

Answer and Explanation

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

Administer furosemide IV: Furosemide is a diuretic used to manage fluid overload, which is not the primary concern in this scenario. The client presents with chest pain suggestive of a cardiac event, so other interventions should take priority.

Prepare the client for intubation: Intubation is not indicated at this stage as the patient is conscious, has a respiratory rate of 18/min, and there is no immediate indication of airway compromise. Oxygen therapy is more appropriate.

Obtain the client’s full family history: While obtaining a full family history is important for a comprehensive assessment, it is not a high priority in the acute management of this client who presents with symptoms suggestive of a myocardial infarction (MI).

Administer O2 to maintain oxygen saturation greater than 90%: The client’s oxygen saturation is 88%, which is below the desired level. Administering oxygen to maintain saturation greater than 90% is a high-priority intervention to improve oxygenation.

Apply continuous ECG monitoring: Continuous ECG monitoring is essential in this scenario to monitor for arrhythmias and assess for ongoing ischemia, given the client’s chest pain, irregular pulse, and the high likelihood of an acute coronary syndrome.

Obtain vascular access: Establishing vascular access is a high priority to ensure the ability to administer medications, fluids, and for potential blood draws, especially in an emergency setting where rapid intervention may be necessary.


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Related Questions

Correct Answer is B

Explanation

A. There is no time to wait for a DNR order in an emergency; immediate action is needed.

B. Without a written DNR order, the nurse is legally and ethically obligated to initiate CPR and call the emergency response team to attempt to save the client’s life.

C. Contacting the risk manager is not an immediate action that would benefit the patient in this emergency situation.

D. The family’s wishes cannot be respected in this scenario without a formal DNR order in place; thus, the nurse must perform CPR.

Correct Answer is B

Explanation

A. While a CVP catheter might be in place for an extended period, its purpose is not directly related to heart healing.

B. The CVP catheter is used to monitor central venous pressure, which helps guide fluid management and assess right heart function.

C. The CVP catheter does not extend into the left ventricle; it is typically positioned in the superior vena cava or right atrium.

D. The CVP catheter may have multiple lumens for administering fluids, but its primary purpose is hemodynamic monitoring, not just providing IV access.

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