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The nurse is reviewing the client's medical record.

Exhibits

For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

A.

Metoprolol 15 mg IV bolus

B.

Oxygen at 2 L/min via nasal cannula

C.

Draw electrolytes along with Hgb and Hct

D.

Morphine 6 mg IV bolus every 3 hr as needed for pain

E.

Nitroglycerin 0.5 mg SL now may repeat every 5 min up to 3 doses

F.

Obtain daily weight

G.

Atropine 0.5 mg IV bolus every 5 min up to 2 mg if heart rate drops below 60

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"B"}}

The client's record indicate that they are experiencing a myocardial infarction due to the elevated markers of inflammation, cardiac biomarkers and typical ECG findings.

Management of myocardial infarction includes oxygen supplementation, nitroglycerin, morphine sulphate, beta blocker such as metoprolol and aspirin/clopidogrel

Among the triggers of myocardial infarction can be cardiac dysrhythmias. This can be caused by electrolytes disturbances and hence the need to draw electrolytes.


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Related Questions

Correct Answer is B

Explanation

Restraints should be avoided whenever possible. Addressing the underlying cause of wandering (such as anxiety, discomfort, or confusion) is essential.
A. In cases where restraints are deemed necessary to prevent harm to the client, such as preventing them from dislodging their tube feeding, it may be appropriate.
C. The use of an abduction pillow is a common preventive measure to maintain proper hip alignment and prevent hip dislocation, especially after hip surgery.
D. Soft heel protectors are used to prevent pressure ulcers and protect the heels from injury while the client is in bed.

Correct Answer is C

Explanation

C. Suspending the infusion of packed RBCs is essential to prevent further administration of the blood product that may be causing the adverse reaction. Stopping the infusion allows for further assessment and appropriate management of the client's symptoms.
A. The client's symptoms of chills, lower back pain, and nausea suggest a potential transfusion reaction rather than respiratory compromise.
B. Collecting a urine sample may be indicated to assess for hemolysis or kidney injury, which can occur as a result of a transfusion reaction. However, this action can be deferred until after immediate interventions to manage the suspected reaction.
D. While checking the client's vital signs is important in assessing the severity of the reaction and the client's overall condition, it is not the first action to take when a transfusion reaction is suspected.

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