Exhibits
A nurse is reviewing the client's diagnostic results and vital signs. Which of the following actions should the nurse take?
Anticipate client to be prepped for cardiac catheterization.
Assist with a continuous heparin infusion.
Encourage the client to ambulate.
Anticipate an increased dosage of metoprolol.
Obtain a prescription for client to be NPO.
Request a prescription for an antibiotic.
Correct Answer : A,B,E
A. The client presents with symptoms and signs suggestive of acute coronary syndrome, including chest pain, tachycardia, and ECG changes (ST segment elevation and T wave changes). Elevated troponin levels indicate myocardial injury. Cardiac catheterization is typically indicated in acute coronary syndrome to assess coronary artery anatomy and potentially perform interventions like angioplasty or stenting to restore blood flow to the heart muscle.
B. Continuous heparin infusion is commonly used in the management of acute coronary syndrome to prevent further clot formation and stabilize the condition. It helps in reducing the risk of thrombus formation in the coronary arteries, which is crucial in cases of myocardial infarction.
C. Ambulation is generally not recommended during the acute phase of myocardial infarction or unstable angina. The client's symptoms, such as chest pain, shortness of breath, and diaphoresis, indicate ongoing cardiac compromise. Ambulation could potentially worsen the client's condition or lead to adverse events.
D. Metoprolol is a beta-blocker used to reduce heart rate, blood pressure, and myocardial oxygen demand. While it is indicated in acute coronary syndrome to stabilize heart rate and reduce myocardial ischemia, increasing the dosage should be done cautiously and based on the client's response to initial therapy.
E. NPO status is typically indicated for clients undergoing procedures that require sedation or anesthesia, such as cardiac catheterization. It ensures the client's stomach is empty to reduce the risk of aspiration during the procedure. Given the potential need for cardiac catheterization in this client, obtaining a prescription for NPO status would be appropriate to prepare for the procedure and ensure safety.
F. Antibiotics are not routinely indicated in the management of acute coronary syndrome unless there is evidence of concomitant infection or specific clinical indications (e.g., pneumonia). In the absence of signs or symptoms of infection, requesting an antibiotic prescription is not warranted based on the client's current presentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Using a raised toilet seat helps maintain the hips above the knees, which is recommended after THA to reduce strain on the hip joint and facilitate safer toileting. Keeping the hips higher than the knees helps prevent excessive flexion of the hip joint, which can strain the surgical site.
A Twisting at the waist places stress on the hip joint and can increase the risk of dislocation, which is a significant concern after THA surgery.
B. This option does not specify the correct procedure for using a walker
D. Heat application, such as using a heating pad, is not recommended for the operative hip after THA. Heat can increase blood flow and inflammation, potentially worsening pain and swelling.
Correct Answer is ["A","B","C","D","E","F"]
Explanation
Restlessness can be a sign of inadequate oxygenation to the brain, known as hypoxia. This is particularly concerning in a client with COPD whose oxygen saturation is already low (87% on room air).
These pulmonary findings indicate worsening respiratory distress in a client with COPD. Tachypnea, productive cough with discolored sputum, and abnormal lung sounds (wheezes and crackles) suggest exacerbation of COPD. The oxygen saturation of 87% on room air is below normal (typically 95% or higher), indicating hypoxemia, which requires immediate assessment and intervention to prevent further respiratory compromise.
The elevated heart rate (110/min) may indicate increased workload on the heart due to respiratory distress and hypoxemia.
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