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A nurse is caring for a newly-admitted client.

Exhibits
The nurse is developing a plan of care with a cardiac rehabilitation team. Which of the following topics should the nurse recommend the team plan to address with the client? Select all that apply.

Cardioversion therapy

Relaxation techniques

Potential pacemaker placement

Blood pressure management

Meal planning ideas

Nitroglycerin self-administration

Physical activity recommendations

Smoking cessation program

Answer and Explanation

Correct Answer : B,D,E,F,G,H

Rationale:

A. Cardioversion therapy: There is no evidence of arrhythmias requiring cardioversion, such as atrial fibrillation or ventricular tachycardia. The client’s rhythm disturbances are not documented, and this is not relevant to their current clinical condition.

B. Relaxation techniques: The client has a long-standing history of generalized anxiety disorder and is exhibiting current anxiety with fear of dying. Incorporating relaxation strategies can reduce cardiac workload, support mental health, and prevent future anxiety-related complications.

C. Potential pacemaker placement: There is no indication of conduction delays, bradyarrhythmias, or heart block that would warrant pacemaker therapy. The client's vital signs and cardiac history do not support this as a current or anticipated need.

D. Blood pressure management: Although BP is currently stable, the client is post-MI with a history of hyperlipidemia and smoking. Ongoing BP control reduces strain on the heart and is vital to secondary prevention of cardiac events and stroke recurrence.

E. Meal planning ideas: The client is dissatisfied with the hospital diet and has no structured dietary practices at home. Providing cardiac-healthy meal planning strategies can improve lipid profile, manage weight, and prevent diet-related risk factor escalation.

F. Nitroglycerin self-administration: The client recently used nitroglycerin effectively for chest pain relief. Education on proper use, frequency, and when to seek emergency care is essential to empower the client in self-management and prevent complications.

G. Physical activity recommendations: The client currently avoids exercise due to fatigue but requires guided activity to support cardiac recovery. Tailored recommendations from rehab experts can improve endurance, reduce fatigue, and promote cardiovascular fitness safely.

H. Smoking cessation program: Although smoking less frequently, the client is still actively smoking. Smoking is a significant modifiable risk factor for recurrent MI and COPD exacerbation. A structured cessation program supports long-term abstinence and respiratory health.

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Free Nursing Study Resources

Correct Answer is D,A,B,C

Explanation

Rationale:

A. Insert the catheter until resistance is felt: The catheter should be gently advanced into the tracheostomy tube until resistance is met, which typically indicates reaching the carina.

B. Withdraw the catheter 1 to 2 cm (0.4 to 0.8 inch): Slight withdrawal prevents trauma to the carina and positions the catheter optimally for effective suctioning.

C. Rotate the catheter while suctioning: Rotating the catheter as suction is applied allows for even clearing of secretions along the tracheal walls and helps prevent localized tissue damage.

D. Lubricate the catheter with sterile saline: Lubrication ensures smooth insertion and reduces trauma to the tracheal mucosa. This is the first action after applying sterile gloves.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

Explanation

Rationale for correct choices:

Opioid intoxication: The client's decreased respiratory rate, drowsiness, pinpoint pupils, and positive response to naloxone are all indicative of opioid intoxication. These features, along with the presence of a needle in the antecubital space, strongly support recent opioid use and CNS depression.
Pupil characteristics: Miotic pupils, or pinpoint pupils, are a classic physical sign of opioid intoxication. They occur due to opioid stimulation of the parasympathetic nervous system, and in a sedated client with a history of injection drug use, they confirm the likelihood of opioid overdose.

Rationale for incorrect choices:

Alcohol intoxication: Alcohol intoxication usually presents with disinhibition, unsteady gait, slurred speech, and potentially aggressive or inappropriate behavior. The client’s severe sedation, low respiratory rate, and constricted pupils are not typical features of alcohol intoxication, especially with only one beer reported.
Alcohol withdrawal: Alcohol withdrawal manifests with symptoms like tremors, agitation, hallucinations, seizures, and autonomic instability (tachycardia, hypertension). This client is sedated with bradypnea and hypotension, which are incompatible with alcohol withdrawal and more suggestive of CNS depression.
Opioid withdrawal: Opioid withdrawal is marked by agitation, anxiety, mydriasis, vomiting, diarrhea, and piloerection. In contrast, this client is drowsy, has decreased bowel sounds, and constricted pupils, pointing toward active opioid intoxication rather than withdrawal.
Amount of alcohol consumed: The report from EMS indicates the client consumed only one beer, which is insufficient to explain the severity of the symptoms. Minimal alcohol intake also makes both intoxication and withdrawal from alcohol highly unlikely as the primary issue.
Current temperature: The client’s current temperature of 37.2°C (99°F) is within normal limits and does not support any particular diagnosis. It neither confirms nor excludes opioid or alcohol intoxication or withdrawal and is not a defining clinical sign in this context.
Breath sounds: Breath sounds are equal and clear, offering no abnormal findings to support or contradict a diagnosis. While important for general assessment, they are not specific indicators for opioid intoxication or withdrawal and thus are less relevant than pupil changes.

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A nurse is caring for a newly-admitted client. Exhibits The nurse is developing a plan of care with a cardiac rehabilitation team. Which of the following topics should the nurse recommend the team plan to address with the client? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a tracheostomy and requires suctioning. Identify the sequence of steps the nurse should follow after applying sterile gloves. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer is D,A,B,C

Explanation

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

Explanation

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A nurse is caring for a newly-admitted client.

Exhibits
The nurse is developing a plan of care with a cardiac rehabilitation team. Which of the following topics should the nurse recommend the team plan to address with the client? Select all that apply.