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The nurse is reviewing the client's medical record.

A nurse is reviewing the client's diagnostic results and vital signs. Which of the following actions should the nurse take? Select all that apply.

Anticipate client to be prepped for cardiac catheterization.

Assist with a continuous heparin infusion.

Encourage the client to ambulate.

Anticipate an increased dosage of metoprolol.

Obtain a prescription for client to be NPO.

Request a prescription for an antibiotic.

Answer and Explanation

Correct Answer : A,B,E

Anticipate client to be prepped for cardiac catheterization: Given the client's diagnosis of myocardial infarction and persistent chest pain, cardiac catheterization may be necessary for evaluating coronary artery patency and determining the need for potential interventions such as angioplasty or stenting. Prepping the client for this procedure is appropriate.
Assist with a continuous heparin infusion: Heparin is often used in acute coronary syndrome management to prevent thrombus formation and reduce the risk of further myocardial injury. Initiating a continuous heparin infusion may be indicated following an assessment of the client’s condition and provider orders.
Encourage the client to ambulate: While early ambulation is important for recovery and preventing complications, in the acute phase of a myocardial infarction, clients should be closely monitored and may require bed rest initially. Encouraging ambulation should only occur once the client is stable and after consulting with the healthcare provider.
Anticipate an increased dosage of metoprolol: Metoprolol is typically administered to manage heart rate and blood pressure, but the dosage should be based on the client’s current vital signs and response to treatment. If the client’s heart rate remains elevated or if there are signs of ongoing ischemia, an increased dosage may be necessary, but this should be based on provider orders rather than an automatic assumption.
Obtain a prescription for client to be NPO: Clients scheduled for procedures such as cardiac catheterization often require NPO status to prevent aspiration during sedation. Additionally, if the client is experiencing nausea, keeping them NPO can prevent further complications.
Request a prescription for an antibiotic: There is no indication of an infection or a need for antibiotic therapy. Antibiotics are typically not indicated for the management of myocardial infarction unless there is a concurrent infection. Therefore, requesting an antibiotic prescription is not appropriate.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Applying a vest restraint daily at bedtime is inappropriate because restraints should only be used as a last resort when other interventions have failed. Restraints must be ordered based on ongoing assessment rather than routine use, as they pose risks such as impaired circulation, skin breakdown, and decreased mobility.

B. Soft heel protectors help prevent pressure injuries and provide cushioning for clients at risk of skin breakdown. They are a non-restrictive intervention and do not require verification with the provider.

C. An abduction pillow helps maintain proper hip alignment and prevents dislocation in clients following hip surgery. This is a standard postoperative intervention that does not require additional verification.

D. Mitten restraints are a less restrictive alternative to wrist restraints and may be used to prevent a client from interfering with medical devices. However, their use still requires a provider's order and close monitoring to ensure patient safety.

A. I have a sore that won't get better on my right foot." B. Client removed gauze bandage to reveal open wound 3 cm x 4 cm on right foot C. draining small amount of purulent drainage D. frequent urination E. increased thirst F. recent 4.5 kg (10 lb) weight loss without trying G. Temperature 38.3° C (100.9°F) H. Heart rate 104/min I. Blood pressure 98/74 mm Hg J. Blood glucose 250 mg/dL (74 to 106 mg/dL)

Correct Answer is ["C","D","E","F","G","H","I","J"]

Explanation

Open wound on right foot with purulent drainage: A non-healing wound with purulent drainage suggests infection, which is a major concern in clients with hyperglycemia. Poor wound healing is common in diabetes due to impaired circulation and immune function.
Frequent urination, increased thirst, and unexplained 4.5 kg (10 lb) weight loss: Classic symptoms of hyperglycemia and possible diabetes mellitus. Polyuria and polydipsia result from osmotic diuresis due to high blood glucose levels, while unexplained weight loss may indicate the body breaking down fat and muscle for energy.
Temperature 38.3° C (100.9° F): Fever indicates a possible systemic infection. In diabetic clients, infections can progress rapidly and lead to complications such as cellulitis, osteomyelitis, or sepsis.
Heart rate 104/min: Tachycardia may be a response to fever, dehydration, or underlying infection. Persistent tachycardia could indicate worsening sepsis or hemodynamic instability.
Blood pressure 98/74 mm Hg: While not critically low, this blood pressure is on the lower end and could indicate early signs of dehydration from polyuria or systemic infection.
Blood glucose 250 mg/dL: Significantly elevated blood glucose suggests poor glycemic control, increasing the risk of infection, delayed wound healing, and diabetic ketoacidosis (DKA) if it continues to rise.:

Respiratory rate 18/min: A normal respiratory rate does not indicate respiratory distress or metabolic compensation.
Oxygen saturation 97% on room air: Oxygenation is within the normal range, suggesting no immediate hypoxia.
WBC count 9,500/mm³: Within the normal range, although an infection may still be present given the fever and purulent wound drainage.
Triiodothyronine (T3) 200 mg/dL: Within normal limits, ruling out thyroid dysfunction as a cause of symptoms.
BMI 27: Slightly overweight but not directly contributing to the acute condition.

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The nurse is reviewing the client's medical record. A nurse is reviewing the client's diagnostic results and vital signs. Which of the following actions should the nurse take? Select all that apply.

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Correct Answer is A

Explanation

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Explanation

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