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Exhibits

The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up:

Blood glucose level

Bowel sounds

Blood pressure

Pain level

Electrocardiogram findings

Lung sounds

Troponin T level

Answer and Explanation

Correct Answer : C,D,E,G

C. The blood pressure readings show significant variability (164/80 mm Hg at 1000, 176/82 mm Hg at 1015, and 110/62 mm Hg at 1200). These fluctuations, especially the higher readings, indicate potential instability and require close monitoring and possibly intervention.
D. The client's pain level is described as 7/10 initially (1000) and decreases to 5/10 after nitroglycerin (1200). Although the pain has decreased, ongoing assessment is necessary to ensure it does not worsen or change in nature.
E. The 12-lead electrocardiogram (ECG) shows tachycardia with ST segment elevation and T wave changes, which are indicative of myocardial ischemia or infarction. This finding requires immediate attention as it suggests ongoing cardiac damage.
G. The troponin T level is elevated at 0.40 ng/mL (normal is less than 0.1 ng/mL). Troponin elevation indicates myocardial injury or infarction and confirms the seriousness of the cardiac event. This finding requires immediate attention to assess the extent of myocardial damage and guide further treatment.

Incorrect Choices
A. While it is slightly elevated, it is not significantly outside the normal range and does not suggest immediate danger or require urgent intervention in the context of the acute cardiac issue. However, monitoring blood glucose levels is important for overall management, especially in a client with diabetes mellitus.
B. The assessment of bowel sounds being present in all 4 quadrants is a normal finding and indicates normal gastrointestinal function. While bowel sounds are important for assessing gastrointestinal health, they are not immediately pertinent to the acute cardiac issue described in the scenario.
F. The nurse notes that lung sounds are clear to auscultation in all lobes, which is a normal finding. Clear lung sounds suggest normal respiratory function and do not require immediate attention in the context of the acute cardiac event described.

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Correct Answer is A

Explanation

A Nitroglycerin is a vasodilator that helps relieve angina by dilating blood vessels and increasing blood flow to the heart muscle. It is typically the first-line medication for acute angina attacks. Administering nitroglycerin promptly can help alleviate the client's pain and prevent progression to a myocardial infarction (heart attack).

B. Aspirin is often administered to clients with suspected myocardial ischemia or infarction because it inhibits platelet aggregation, which can reduce the risk of clot formation and further occlusion of coronary arteries. It is typically given early in the management of acute coronary syndrome to prevent clotting complications.

C. While monitoring blood pressure is important in clients with acute angina, especially to assess for hypotension which could indicate cardiogenic shock, it is not the first action. Immediate pain relief and prevention of further ischemic damage take precedence over blood pressure measurement.

D. IV access is important for administering medications and fluids if needed, but it is not the first priority unless the client's condition warrants immediate IV medication administration (such as in severe pain or impending myocardial infarction).

A. The client advances the weaker leg forward to the cane. B. The client holds the cane with their left hand. C. The client takes a step with their right foot first. D. The client moves the cane 2 feet ahead.

Correct Answer is A

Explanation

A Advancing the weaker leg forward to the quad cane first indicates that the client understands the proper sequence of using the cane to support their weaker side. This action provides stability and reduces the risk of falls or imbalance.

B. Holding the cane with the opposite hand of the weaker side (right hand, in this case) is crucial to provide proper support and balance while walking. This distributes weight evenly and enhances stability.

C. Taking a step with the stronger foot first does not effectively support the weaker side and can lead to imbalance or falls, especially for a client with left-sided weakness.

D. While moving the cane ahead with each step is necessary, the distance of two feet is not specified in proper cane use. The cane should move forward incrementally with each step to maintain stability and support.

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Exhibits The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has acute angina. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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Exhibits

The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up: