A nurse is caring for a client in the emergency departmen

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

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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Correct Answer is D

Explanation

A. A coronary artery bypass graft is used to treat coronary artery disease but is not typically indicated for end-stage heart failure.
B. Percutaneous coronary intervention is also used for coronary artery disease, not for improving quality of life in terminal heart failure.
C. This option dismisses potential interventions that could improve quality of life, such as an LVAD.
D. An LVAD is a mechanical pump that assists the left ventricle in pumping blood, often used as a bridge to heart transplant or as a long-term solution to improve quality of life in patients with terminal heart failure.

A. Secondary hypertension B. Hypertensive urgency C. Hypertensive emergency D. Primary hypertension

Correct Answer is C

Explanation

A. Secondary hypertension is high blood pressure due to an identifiable cause, such as renal disease, but it does not describe an acute situation with target organ damage.

B. Hypertensive urgency is a situation where the blood pressure is severely elevated but without evidence of target organ damage.

C. Hypertensive emergency is characterized by severely elevated blood pressure with evidence of acute target organ damage, such as encephalopathy, myocardial infarction, or renal failure, requiring immediate medical intervention.

D. Primary hypertension, also known as essential hypertension, is high blood pressure without a known secondary cause and does not describe an acute emergency.

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Naxlex Comprehensive Predictor Exams

A patient was admitted for terminal heart failure and is now eligible for a transplant. The family wants everything possible done to maintain life. Which procedure might be offered to the patient for this condition to increase the patient's quality of life?

Correct Answer is D

Explanation

Which of the following describes a situation in which the blood pressure is severely elevated and there is evidence of actual target organ damage?

Correct Answer is C

Explanation

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