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 B
Explanation
B. This is often the nurse's top priority in the PACU. Anesthesia can depress respiratory function, leading to hypoventilation or airway obstruction. The nurse assesses respiratory rate, effort, oxygen saturation, and auscultates breath sounds to ensure adequate ventilation. Addressing any respiratory compromise promptly is crucial to prevent hypoxia or respiratory arrest.
A Assessing the surgical site is important to monitor for bleeding, infection, or any other complications related to the procedure. However, immediately after surgery, other assessments take precedence over this unless there is a specific concern like excessive bleeding or signs of infection.
C. Monitoring the client's level of consciousness is vital to detect any signs of neurological complications or delayed emergence from anesthesia. The nurse assesses orientation, responsiveness, and neurological signs to ensure the client is awakening appropriately from anesthesia.
D. Assessing pain is important as clients may experience discomfort after surgery. Pain can also affect respiratory function and overall recovery. However, it is typically assessed after ensuring respiratory status and consciousness are stable, as uncontrolled pain can be managed once immediate physiological concerns are addressed.
Correct Answer is A
Explanation
A Pain typically occurs when the stomach is empty (1-3 hours after eating), often during the night and early morning. This pattern occurs because the presence of food helps to buffer gastric acid, whereas an empty stomach allows acid to directly contact the ulcerated area, leading to pain.
B. Pain in the right lower quadrant is not typically associated with peptic ulcer disease. Pain in PUD is usually located in the epigastric region (upper abdomen), although it can radiate to the back or other areas depending on the location and severity of the ulcer.
C. Constipation is not a typical finding in peptic ulcer disease. PUD is primarily associated with gastrointestinal symptoms related to acid-peptic imbalance, such as abdominal pain, bloating, nausea, and sometimes vomiting. Bowel habits are generally not directly affected by PUD.
D. In peptic ulcer disease, pain is usually relieved by eating or taking antacids. This is because food intake neutralizes gastric acid and provides a temporary protective coating over the ulcer, reducing irritation and pain.
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