Exhibits
Complete the following sentence by using the lists of options.
The nurse should first address the client
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).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Monitoring urine output is crucial in the early postoperative period after a kidney transplant to assess kidney function and ensure adequate perfusion.
A Managing pain is important, but the administration of opioids should be carefully considered due to their potential to mask symptoms and side effects that could be critical in the postoperative period.
B. While electrolyte imbalances are important to monitor, hypokalemia specifically is not typically associated with acute rejection in the early postoperative period.
D. Blood pressure monitoring every 8 hours may not be sufficient in the immediate postoperative period, especially given the potential for fluid shifts and changes in hemodynamic status.
Correct Answer is A
Explanation
A A change in level of consciousness (LOC), such as confusion, lethargy, or loss of consciousness, can indicate worsening neurological status. It reflects impaired brain function due to increased pressure on brain tissues.
B. Pupillary changes, such as dilation or asymmetry, can occur due to pressure on the oculomotor nerve (cranial nerve III). Pupillary dilation can be a sign of increased ICP but typically occurs after other neurological changes.
C. Decorticate posturing indicates significant neurological impairment but typically appears after alterations in consciousness.
D. Cheyne-Stokes respirations indicate brainstem involvement and impaired respiratory control but are generally seen later in the progression of neurological deterioration.
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