Exhibits
For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.
Metoprolol 5 mg every 2 to 3 min up to three doses
Oxygen at 2 L/min via nasal cannula
Draw electrolytes along with Hgb and Hct
Morphine 6 mg IV bolus every 3 hr as needed for pain
Nitroglycerin 0.4 mg SL now may repeat every 5 min up to 3 doses
Obtain daily weight
Atropine 0.5 mg IV bolus every 5 min up to 2 mg
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"C"}}
Metoprolol 5 mg every 2 to 3 min up to three doses
Nonessential: Metoprolol is a beta-blocker used to reduce heart rate and blood pressure. However, in this scenario, the client already has a history of irregular heart rate and is currently tachycardic. Starting metoprolol at this frequency and dose without knowing the client's response or stability could exacerbate their condition. Therefore, it is considered nonessential until further assessment and stabilization.
Oxygen at 2 L/min via nasal cannula
Anticipated: The client's oxygen saturation dropped to 89% at 1015 and improved to 92% with oxygen supplementation by 1200. Given the client's symptoms and fluctuating oxygen saturation, supplemental oxygen is necessary to ensure adequate tissue oxygenation and is anticipated to support respiratory function.
Draw electrolytes along with Hgb and Hct
Nonessential: While electrolyte levels (such as potassium) are important to monitor, they are not immediately critical in the management of acute myocardial infarction or unstable angina. They can be drawn later for comprehensive assessment but are not urgently needed in the acute phase of care.
Morphine 6 mg IV bolus every 3 hr as needed for pain
Anticipated: Morphine is indicated for managing severe pain, such as chest pain associated with myocardial infarction. The client reported significant chest pain (7/10 initially), and morphine is appropriate to alleviate discomfort and reduce myocardial oxygen demand.
Nitroglycerin 0.4 mg SL now may repeat every 5 min up to 3 doses
Anticipated: Nitroglycerin is a vasodilator that helps relieve chest pain associated with angina or myocardial infarction by dilating coronary arteries. Given the client's chest pain and the protocol for administering nitroglycerin, it is anticipated to be effective in managing symptoms and improving coronary blood flow.
Obtain daily weight
Nonessential: Daily weight monitoring is useful for assessing fluid status in some conditions, but it is not immediately necessary in the acute management of myocardial infarction or unstable angina unless there are signs of fluid overload or heart failure, which are not evident in this case.
Atropine 0.5 mg IV bolus every 5 min up to 2 mg
Contraindicated: Atropine is used to treat bradycardia (slow heart rate). However, the client in this scenario is tachycardic (rapid heart rate), and atropine would exacerbate this condition. Therefore, it is contraindicated and should not be administered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Nuchal rigidity refers to stiffness or resistance to neck movement, especially when the client's head is flexed forward. It is a classic sign of meningitis due to irritation and inflammation of the meninges (the membranes surrounding the brain and spinal cord). This assessment helps to detect meningeal irritation, a hallmark of meningitis.
B. This action tests the deep tendon reflex, specifically the knee jerk reflex (patellar reflex). It assesses the integrity of the spinal cord and peripheral nerves. While it is part of a neurological assessment, it is not specifically related to the assessment of meningitis unless there are concurrent neurological symptoms or signs.
C This maneuver tests for Babinski reflex, which is an abnormal response where the toes flare upward and the big toe dorsiflexes when the sole of the foot is stimulated. A positive Babinski reflex can indicate dysfunction of the corticospinal tract or brain injury but is not a specific finding in meningitis.
D. Tapping the facial nerve (cranial nerve VII) assesses for the presence of facial nerve irritation or damage. In the context of meningitis, signs such as facial twitching or asymmetry may indicate involvement of cranial nerves due to inflammation and pressure within the skull.
Correct Answer is ["A","B","C","D","E","F"]
Explanation
Restlessness can be a sign of inadequate oxygenation to the brain, known as hypoxia. This is particularly concerning in a client with COPD whose oxygen saturation is already low (87% on room air).
These pulmonary findings indicate worsening respiratory distress in a client with COPD. Tachypnea, productive cough with discolored sputum, and abnormal lung sounds (wheezes and crackles) suggest exacerbation of COPD. The oxygen saturation of 87% on room air is below normal (typically 95% or higher), indicating hypoxemia, which requires immediate assessment and intervention to prevent further respiratory compromise.
The elevated heart rate (110/min) may indicate increased workload on the heart due to respiratory distress and hypoxemia.
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