A nurse on a step-down unit is admitting a client.
Complete the following sentence by using the lists of options.
The nurse should first
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Rationale for correct choices:
- Apply oxygen via nasal cannula: The client’s oxygen saturation levels of 87–88% on room air indicate moderate to severe hypoxemia, requiring immediate correction. Since the client has a history of COPD and is post-MI, improving oxygenation is essential to reduce myocardial workload and prevent further ischemia or respiratory distress.
- Initiating a consult for cardiac rehabilitation: Once the client's immediate needs are stabilized, early initiation of cardiac rehabilitation is appropriate. This supports physical recovery, promotes lifestyle changes like smoking cessation and exercise, and reduces future cardiac risk.
Rationale for incorrect choices:
- Administer a second dose of nitroglycerin: The client’s chest pain has resolved following the initial dose, so there is no current indication to give a second dose. Re-administering nitroglycerin unnecessarily can lead to hypotension or reflex tachycardia, especially risky in a post-MI patient.
- Request a prescription for a PRN anxiolytic: The client has already been prescribed alprazolam 0.5 mg three times daily, and their anxiety has improved. Requesting an additional anxiolytic is unnecessary at this point and does not address the more urgent issue of low oxygen saturation.
- Requesting a prescription for a WBC count: There are no signs or symptoms of infection such as fever, chills, or elevated WBC to justify this request. The focus should remain on the client’s cardiopulmonary status and rehabilitation rather than diagnostics that are not clinically indicated.
- Administering a bolus of fluids: There is no clinical indication of fluid volume deficit, hypotension, or dehydration. Administering fluids to a post-MI patient with COPD may lead to fluid overload, pulmonary edema, or increased myocardial strain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Explanation
Rationale for correct choices:
- Placental abruption: Hypertension in pregnancy increases the risk of premature separation of the placenta from the uterine wall. In this case, the elevated BP combined with symptoms like right upper quadrant pain and hyperreflexia suggests a potential complication such as placental abruption.
- Hypertension: A blood pressure of 148/94 mm Hg is above the diagnostic threshold for gestational hypertension. When paired with signs like restlessness, headache, and hyperreflexia, it raises concern for preeclampsia, a known risk factor for placental abruption.
Rationale for incorrect choices:
- Placenta previa: Characterized by painless bleeding in the second or third trimester and associated with abnormal placental placement, not hypertension. The client has no bleeding or ultrasound findings consistent with previa.
- Oligohydramnios: Typically linked to fetal or placental insufficiency or rupture of membranes. No findings in this case suggest low amniotic fluid or related complications.
- Spontaneous abortion: This term applies before 20 weeks’ gestation. The client is 30 weeks pregnant with no signs of fetal demise or expulsion, so this condition does not apply.
- Chorioamnionitis: Requires signs of infection such as fever, uterine tenderness, or foul-smelling discharge. The client is afebrile and has clear lung sounds, making infection unlikely.
- Temperature: The recorded temperature is within normal range (37.4°C), so it does not suggest infection or another abnormality requiring urgent follow-up.
- Vomiting: Common in pregnancy and non-specific unless persistent or linked with abnormal labs. Here, it appears as an isolated symptom and does not directly imply risk of abruption.
- Hyperreflexia: While a sign of preeclampsia, it is secondary to hypertension. It supports the presence of a hypertensive disorder but is not the primary cause of abruption.
- Fundal measurement: A fundal height of 29 cm is normal for 30 weeks’ gestation and does not indicate fetal growth restriction or excess fluid that might signal a complication.
Correct Answer is B
Explanation
Rationale:
A. Probiotics: Probiotics are used to support gastrointestinal and immune health and do not significantly affect blood pressure or pose a known risk for intraoperative hypotension.
B. Black Cohosh: Black cohosh is often used to manage menopausal symptoms and is known to cause vasodilation, which can lower blood pressure. When combined with anesthetic agents, it can potentiate hypotensive effects during surgery.
C. Soy: Soy is consumed for its phytoestrogenic effects but does not have a direct or significant hypotensive action that increases surgical risk. Its impact on intraoperative blood pressure is minimal.
D. Flaxseed: Flaxseed may offer mild antihypertensive effects over time due to its omega-3 content, but it is not typically associated with clinically significant drops in blood pressure during surgery.
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