The nurse is caring for a client.
Which of the following actions should the nurse take? Select all that apply.
Prepare for chest tube placement.
Ensure that the client has venous access.
Place the client in High Fowler's position.
Activate the rapid response team.
Administer fondaparinux as prescribed.
Administer midazolam as prescribed.
Correct Answer : B,C,D,E
A. Prepare for chest tube placement: Chest tube placement is indicated for conditions like pneumothorax or pleural effusion, which are not clearly present in this scenario. Immediate interventions should focus on stabilizing the client and evaluating cardiopulmonary status first.
B. Ensure that the client has venous access: Establishing IV access is essential for rapid administration of medications, fluids, or emergency interventions if the client’s condition deteriorates. This is a priority in acute postoperative complications.
C. Place the client in High Fowler's position: Elevating the head of the bed improves lung expansion, reduces dyspnea, and enhances oxygenation in a client experiencing sudden respiratory distress and crackles, which may indicate pulmonary edema or fluid overload.
D. Activate the rapid response team: The client exhibits acute respiratory distress, hypoxemia, tachypnea, and cardiovascular changes. Activating the rapid response team ensures timely advanced intervention and evaluation to prevent further deterioration.
E. Administer fondaparinux as prescribed: Postoperative clients following total hip arthroplasty are at high risk for venous thromboembolism. Administering anticoagulant therapy, such as fondaparinux, helps prevent pulmonary embolism, which could be causing the client’s sudden dyspnea.
F. Administer midazolam as prescribed: Midazolam is a sedative and would not address the client’s acute respiratory distress. Sedation could worsen hypoxemia and respiratory compromise in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administer a dose of fluoxetine to the client: Fluoxetine is an antidepressant and is not indicated for acute psychotic symptoms such as auditory hallucinations in schizophrenia. Antipsychotic medications, not SSRIs, are the standard treatment for managing hallucinations.
B. Avoid making eye contact with the client: Avoiding eye contact can be perceived as disengagement or disinterest, which may increase the client’s anxiety or mistrust. Therapeutic communication with appropriate eye contact helps establish rapport and conveys presence and support.
C. Request the client to lie down in a quiet room: Forcing the client to lie down may increase distress or feelings of loss of control. While a quiet environment can reduce stimuli, the intervention should be voluntary and focused on coping strategies rather than directives.
D. Encourage the client to listen to music: Listening to music can help distract the client from hallucinations and provide a coping mechanism to reduce distress. This intervention supports safety, comfort, and engagement without confrontation, aligning with therapeutic approaches for managing auditory hallucinations.
Correct Answer is C
Explanation
A. The client's activity level: Physical activity is a modifiable risk factor because the client can increase exercise to reduce cardiovascular risk. Lifestyle changes in activity level can significantly impact heart health and recovery after a myocardial infarction.
B. The client's stress level: Stress is a modifiable risk factor as clients can employ stress-reduction techniques, counseling, or lifestyle modifications to lower cardiovascular risk. Managing stress can improve both short-term and long-term cardiac outcomes.
C. The client's race: Race is a nonmodifiable risk factor because it is inherent and cannot be changed. Certain racial and ethnic groups have a higher prevalence of cardiovascular disease due to genetic, socioeconomic, and health access factors.
D. The client's diet: Diet is a modifiable risk factor since clients can adjust their nutritional intake to reduce cholesterol, blood pressure, and overall cardiovascular risk. Nutritional counseling is often part of post-MI care to improve outcomes.
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