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Exhibits

Complete the following sentence by using the lists of options.

The nurse should first address the client

followed by the client's

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

The nurse should first address the client pain level followed by the client's ECG results

Rationale

Pain level: Addressing the client's pain level is crucial because it directly affects their comfort and can be indicative of ongoing myocardial ischemia or infarction. The client initially reported chest pain as 7/10, which is significant. Although it has decreased to 5/10 after nitroglycerin, ongoing assessment of pain is essential to ensure it does not worsen or change in nature.

ECG results: The 12-lead electrocardiogram (ECG) shows tachycardia with ST segment elevation and T wave changes. These findings indicate acute myocardial ischemia or infarction, which is a critical concern. The ECG results guide further diagnosis and treatment decisions, such as determining the need for immediate reperfusion therapy (like thrombolytics or angioplasty).


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Related Questions

Correct Answer is B

Explanation

B. This location is preferred because it provides rapid and higher peak plasma epinephrine levels compared to other sites, which is crucial during an anaphylactic emergency.

A While this can be a safe IM injection site in some adults, it's not the preferred location for epinephrine during anaphylaxis. The muscle mass in the ventrogluteal area might be less reliable for quick absorption of the medication in an emergency situation.

C. avoided due to its proximity to major nerves (sciatic nerve) and blood vessels, which can lead to complications such as nerve damage or accidental injection into a blood vessel.

D. The deltoid is generally not recommended because it has a smaller muscle mass compared to the ventrogluteal or vastus lateralis sites.

Correct Answer is B

Explanation

B. The appropriate action for a nurse to take would be to check for air leaks in the system. This can be done by clamping the tubing momentarily to see if the bubbling stops, which would suggest the presence of a leak.

A The drainage system should always be kept below the level of the chest and should not be raised or emptied unless specifically indicated.

C. Emptying the collection chamber is typically unnecessary unless it is nearing full capacity. Continuous bubbling in the water seal chamber does not indicate that the collection chamber needs immediate emptying.

D. Squeezing the tubing can disrupt the functioning of the drainage system and is not recommended. Drainage should flow passively into the collection chamber without external manipulation.

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