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 A
Explanation
A Advancing the weaker leg forward to the quad cane first indicates that the client understands the proper sequence of using the cane to support their weaker side. This action provides stability and reduces the risk of falls or imbalance.
B. Holding the cane with the opposite hand of the weaker side (right hand, in this case) is crucial to provide proper support and balance while walking. This distributes weight evenly and enhances stability.
C. Taking a step with the stronger foot first does not effectively support the weaker side and can lead to imbalance or falls, especially for a client with left-sided weakness.
D. While moving the cane ahead with each step is necessary, the distance of two feet is not specified in proper cane use. The cane should move forward incrementally with each step to maintain stability and support.
Correct Answer is D
Explanation
D. A weight loss of 1.8 kg (4 lb) in the past 24 hours indicates effective diuresis (urine output) and reduction in fluid volume, which is the therapeutic goal of furosemide in treating pulmonary edema.
A Furosemide is a loop diuretic that typically causes a decrease in blood pressure by promoting the excretion of excess fluid and sodium from the body.
B. Adventitious breath sounds such as crackles (rales) indicate the presence of fluid in the lungs, which is a characteristic finding in pulmonary edema.
C. A respiratory rate of 24 breaths per minute is within normal range for an adult at rest. While this respiratory rate is not abnormal, it also does not directly indicate whether furosemide is effective in treating pulmonary edema.
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