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.
Administer furosemide IV
Prepare the client for intubation
Obtain the client’s full family history
Administer O2 to maintain oxygen saturation greater than 90%
Apply continuous ECG monitoring
Obtain vascular access
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Continuous IV infusion is the most appropriate route for treating hypertensive emergencies because it allows for rapid and controlled reduction of blood pressure, which is crucial in preventing target organ damage.
B. Sublingual administration is not recommended in hypertensive emergencies because it does not allow for the precise control needed in these situations.
C. Intramuscular administration is generally not used for antihypertensive agents in emergencies because it does not provide the rapid and adjustable response that IV infusion does.
D. Oral administration is too slow in onset for hypertensive emergencies and is not appropriate when immediate blood pressure control is necessary.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}
Explanation
Furosemide: Furosemide is a diuretic that is commonly used to manage fluid overload in patients with heart failure. The patient has significant pitting edema, increasing dyspnea, and elevated BNP levels, indicating worsening heart failure. Administering furosemide is a high priority to reduce fluid overload and relieve symptoms.
Echocardiogram: An echocardiogram can provide valuable information about heart function.
Aspirin: Aspirin is typically used for its antiplatelet effects in conditions like coronary artery disease. It is not essential for managing acute symptoms of heart failure. The patient’s primary issue is fluid overload rather than a clotting concern.
Losartan: Losartan, an angiotensin II receptor blocker (ARB), is commonly used in the management of chronic heart failure to reduce afterload and prevent further cardiac remodeling. It is essential as part of the long-term management plan for heart failure.
Cardiac catheterization: Cardiac catheterization is an invasive procedure typically used to assess coronary artery disease or for interventional procedures. It is not indicated for the acute management of heart failure symptoms and could pose unnecessary risks in this context.
Chest X-ray: A chest X-ray is essential to assess the extent of pulmonary congestion and rule out other causes of respiratory distress, such as pneumonia or pleural effusion, which are important in managing a patient with worsening heart failure.
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