A nurse is reviewing the client’s medical record

Exhibits

For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Potential Prescription: Anticipated Nonessential Contraindicated

Metoprolol 15 mg IV bolus

Oxygen at 2 L/min via nasal cannula

Draw electrolytes along with Hgb and Hct

Morphine 6 mg IV bolus every 3 hr as needed for pain

Nitroglycerin 0.5 mg SL now may repeat every 5 min up to 3 doses

Obtain daily weight

Atropine 0.5 mg IV bolus every 5 min up to 2 mg if heart rate drops below 60

Answer and Explanation

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

A)   Metoprolol is a beta-blocker that can help reduce heart rate and blood pressure, which is beneficial in cases of chest pain and irregular tachycardia.
B)   Oxygen at 2 L/min via nasal cannula is anticipated because the client's oxygen saturation is below normal, indicating they may benefit from supplemental oxygen.
C)   Drawing electrolytes along with Hgb and Hct is anticipated as it is important to monitor these levels due to the client's symptoms and history of hypertension and diabetes.
D)   Morphine is anticipated because the client reports pain, and morphine can provide pain relief and reduce the workload on the heart.
E)   Nitroglycerin is a standard treatment for chest pain due to its vasodilating effects, which can improve blood flow to the heart.
F)   Obtaining daily weight is nonessential at this moment because it does not directly address the acute symptoms the client is experiencing.
G)   Atropine is contraindicated as the client's heart rate is tachycardic, not bradycardic, and atropine is used to increase heart rate.

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Correct Answer is ["Pain level","ECG results"]

Explanation

The client's pain level should be addressed first based on the principle of prioritizing interventions according to the client's immediate needs and potential severity of the condition. Chest pain, especially when radiating to the left arm, is a concerning symptom that can indicate myocardial ischemia or infarction. It is essential to promptly assess and manage the client's pain to provide relief and potentially mitigate further cardiac damage. In this scenario, the client rates the pain as 7 out of 10, indicating moderate to severe discomfort, which warrants immediate attention.

A. Encourage the client to cough. B. Keep the client's head in a midline position. C. Elevate the head of the bed. D. Assist the client to the bathroom. E. Initiate seizure precautions. F. Decrease oxygen to 1.5 L/min via nasal cannula.

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

Explanation

A) Coughing is not directly related to the client's condition as described in the scenario.
B) Keeping the client's head in a midline position is anticipated to maintain an open airway and prevent further complications, particularly after a cerebrovascular accident.
C) Elevating the head of the bed is anticipated as it can help improve respiratory function and reduce intracranial pressure, which is beneficial given the client's history of cerebrovascular accident and current restlessness and agitation.
D) Assisting the client to the bathroom is contraindicated due to the client's current unresponsiveness and risk of falls; a bedpan or catheter may be more appropriate.
E) Initiating seizure precautions is anticipated because the client's Glasgow Coma Scale score indicates a decreased level of consciousness, which could predispose them to seizures, especially with a history of cerebrovascular accident.
F) Decreasing oxygen to 1.5 L/min via nasal cannula is contraindicated given the client's decreased oxygen saturation levels; instead, the nurse should anticipate the need to maintain or increase oxygen to ensure adequate tissue perfusion.

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A nurse is reviewing the client’s medical record Exhibits For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. Potential Prescription: Anticipated Nonessential Contraindicated

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Exhibits Complete the following sentence by using the lists of options. The nurse should first address the client's Select... followed by the client's Select...ECG results

Correct Answer is ["Pain level","ECG results"]

Explanation

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

Explanation

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A nurse is reviewing the client’s medical record

Exhibits

For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Potential Prescription: Anticipated Nonessential Contraindicated