A patient with a cardiac disorder is having increased premature ventricular contractions and feels "anxious" and short of breath. After vital signs are obtained, what actions should the nurse take? Select all that apply.

Notify the health-care provider.

Start oxygen at 2 L/min.

Order an electrocardiogram and cardiac enzymes.

Place bed in modified Trendelenburg position.

Allow the patient to rest alone.

Elevate the head of the bed.

Answer and Explanation

Correct Answer : A,B,C,F

A.   Increased premature ventricular contractions along with symptoms of anxiety and shortness of breath may indicate worsening cardiac function or an acute cardiac event, necessitating immediate medical attention.
B.   Oxygen therapy may help alleviate symptoms of shortness of breath and improve oxygenation in patients experiencing cardiac symptoms.
C.   These diagnostic tests can provide valuable information about cardiac function and any potential myocardial damage or ischemia, helping guide further treatment and management.
D.   The modified Trendelenburg position may increase cardiac workload, which is not beneficial in the case of PVCs.
E.   The patient should not be left alone due to the need for ongoing assessment and potential rapid intervention. Furthermore, leaving them alone could worsen their anxiety.
F.   Elevating the head of the bed can aid in breathing and comfort, reducing the sensation of breathlessness.

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Correct Answer is D

Explanation

A. A specific gravity within the normal range indicates adequate urine concentration and hydration status, which is not typically concerning.
B. This color is indicative of normal urine concentration and hydration status and is not necessarily indicative of urinary tract pathology.
C. Absence of glucose in the urine is a normal finding and does not typically warrant further investigation.
D. Microscopic hematuria (blood in the urine not visible to the naked eye) may indicate underlying urinary tract pathology, such as infection, inflammation, or kidney stones, and should be reported to the provider for further evaluation and management.

A. Swab teeth and mucous membranes four times daily with lemon-glycerin swabs B. Brush teeth twice a day with a firm toothbrush C. Use sponge Toothettes to clean teeth between meals D. Use waxed floss between meals and at bedtime

Correct Answer is C

Explanation

A. Lemon-glycerin swabs can dry out and irritate oral tissues, increasing the risk of oral mucositis and infection.
B. Using a firm toothbrush may be too harsh for irritated mucous membranes and can increase the risk of injury and bleeding.
C. Gentle oral care is essential to avoid further irritation of the mucous membranes.

D. Flossing may be too abrasive for irritated mucous membranes and can increase the risk of bleeding and injury.

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A patient with a cardiac disorder is having increased premature ventricular contractions and feels "anxious" and short of breath. After vital signs are obtained, what actions should the nurse take? Select all that apply.

Nursing Test Bank

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