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 D
Explanation
D. Edema is expected in the initial hours and days following major burns and can be particularly pronounced in full-thickness burns due to extensive tissue damage and inflammation.
A Initially, full-thickness burns may not be as painful due to nerve damage; however, surrounding areas with partial-thickness burns or areas where nerve endings are intact can be extremely painful. The absence of severe pain at the site of full-thickness burns is common initially due to nerve damage, but pain management is crucial as inflammation progresses.
B. Full-thickness burns typically involve destruction of the entire epidermis and dermis, leading to the absence of blisters. Blisters are characteristic of partial-thickness burns, where the epidermis is partially damaged but not completely destroyed.
C. Epithelialization refers to the process of new skin cells migrating and covering the wound, a process that occurs during the later stages of wound healing. In the acute phase of full-thickness burns, epithelialization does not occur because the skin layers are completely destroyed. This process starts later once the wound has been adequately debrided and begins to heal.
Correct Answer is D
Explanation
A Breathing exercises can help improve lung function and oxygenation. However, the specific type of breathing exercise is crucial. Emphysema typically involves air trapping due to loss of elasticity in the lungs, so teaching a breathing exercise with a longer exhalation phase (to facilitate complete exhalation and prevent air trapping) would be more beneficial than emphasizing a longer inhalation phase.
B. Fluid restriction is not typically indicated for clients with emphysema. It is more relevant for conditions where fluid overload can exacerbate symptoms (like congestive heart failure). In emphysema, maintaining adequate hydration is important to keep secretions thin and more manageable for clearing.
C.Incentive spirometry is used to help promote deep breathing and prevent atelectasis (lung collapse) by encouraging the client to take slow, deep breaths. However, incentive spirometry is typically more useful for clients recovering from surgery or immobilized clients rather than for those with emphysema.
D. The use of oxygen therapy at 2 L/min is a standard intervention for clients with emphysema who have low oxygen levels, as it helps maintain proper oxygenation. It is crucial to manage oxygen levels carefully to prevent complications such as hypoxia or pulmonary hypertension while avoiding excessive oxygen, which may reduce the patient's drive to breathe.
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