Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Myocardial infarction (MI) is suggested by chest pain radiating to the left arm, diaphoresis, shortness of breath, and epigastric discomfort. The pain described as "sharp, tight, and like indigestion" aligns with cardiac ischemia.
Administering oxygen helps improve myocardial oxygenation, reducing ischemia.
Aspirin 325 mg is a standard intervention in suspected MI to prevent further platelet aggregation and reduce the risk of worsening thrombosis in the coronary arteries.
Monitoring vital signs is critical to assess for hemodynamic stability and signs of worsening cardiac function (e.g., hypotension, tachycardia).
Monitoring ECG rhythm helps detect ST-elevation or other ischemic changes and assess for life-threatening arrhythmias.
Morphine may be used for chest pain, but it is now considered secondary to nitroglycerin and beta-blockers.
Verapamil is a calcium channel blocker used for rate control in arrhythmias but is not first-line for acute MI.
Platelet count and WBC count are not immediately relevant to MI management.
Serum glucose levels may be affected by stress but are not a primary concern in acute MI management.

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Correct Answer is D

Explanation

A. Deep palpation of the abdomen is contraindicated in clients with an AAA, as it may cause rupture.
B. A chest X-ray may detect an aneurysm, but it is not the priority assessment.
C. Pain assessment is important, as sudden severe pain could indicate rupture, but it is not the first priority.
D. Blood pressure assessment is the priority, as hypertension can increase the risk of aneurysm rupture. Strict BP control is critical to preventing complications.

A. The client has an INR of 2. B. The client has an aPTT of 80 seconds. C. The client experiences sudden weakness of one arm and leg. D. The client's ECG tracing shows irregular heart rate without P waves.

Correct Answer is C

Explanation

A. An INR of 2 is within the therapeutic range for anticoagulation but is more relevant for warfarin therapy rather than heparin.
B. An aPTT of 80 seconds is slightly elevated but not immediately life-threatening. The therapeutic range for heparin is typically 1.5 to 2.5 times the normal value (approximately 60-80 seconds).
C. Sudden weakness of one arm and leg suggests a possible embolic stroke, which is a serious complication of atrial fibrillation. This requires immediate assessment and intervention.
D. An irregular heart rate without P waves is characteristic of atrial fibrillation but is not the most urgent concern compared to potential stroke symptoms.

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Exhibits Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a history of an abdominal aortic aneurysm (AAA). Which of the following assessments should be the nurse's priority for a client with an abdominal aortic aneurysm?

Correct Answer is D

Explanation

A nurse is caring for a client diagnosed with atrial fibrillation who is receiving continuous IV heparin. Which of the following findings is the nurse's priority?

Correct Answer is C

Explanation

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

A nurse is giving a presentation about preventing deep-vein thrombosis (DVT). Which of the following should the nurse include as a risk factor for this disorder? (Select all that apply.)

A nurse is reviewing blood pressure classifications with a group of nurses at an in-service meeting. Which of the following should the nurse include as a risk factor for the development of hypertension?

A nurse is teaching a newly licensed nurse about evaluating cardiac rhythms. Which of the following best explains calculation of the heart rate?

A nurse is caring for a client who is scheduled for an echocardiogram the following day. Which of the following information should the nurse include about the test?

A nurse is providing teaching to a client who has a family history of hypertension. The nurse should inform the client that their blood pressure readings of 124/84 mm Hg and 128/88 mm Hg place them in which of the following categories?

A nurse is caring for a client who is scheduled for an exercise stress test. Which of the following medications should the nurse hold the morning of the stress test?

A nurse is caring for a client with sudden onset of chest pain, the nurse completes the electrocardiogram (ECG). The nurse understands that this client is having what type of acute coronary syndrome?

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.