A nurse is admitting a client who reports chest pain.

Exhibits

The nurse is preparing the client for the cardiac catheterization. Which of the following actions should the nurse take? (Select all that apply.)

Obtain the client's vital signs.

Witness the client's signature on the Informed consent form.

Confirm the client's allergies.

inform the client of the risks of the procedure.

Mark the surgical site.

Answer and Explanation

Correct Answer : A,B,C

A. Obtain the client's vital signs: This is correct. Vital signs should be assessed to monitor the client's cardiovascular status before any invasive procedure, especially in the context of a myocardial infarction.
B. Witness the client's signature on the informed consent form: This is correct. The nurse should witness the client's signature on the informed consent form, ensuring that the client understands the procedure and consents to it.
C. Confirm the client's allergies: This is correct. Confirming allergies is crucial before any procedure to prevent allergic reactions to medications, contrast dye, or other substances used during the procedure.
D. Inform the client of the risks of the procedure: This is incorrect. It is the responsibility of the provider to explain the risks of the procedure in detail to the client. The nurse ensures that the client understands and that consent is given, but the nurse does not provide the detailed explanation of risks.
E. Mark the surgical site: This is incorrect. Marking the surgical site is typically done by the provider, not the nurse, and is required only if a surgical procedure is being performed, which is not the case for a cardiac catheterization.

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Correct Answer is ["B","C","E"]

Explanation

A. Passive range-of-motion exercises should be avoided in the acute phase of a sprain. Early movement can aggravate the injury and delay healing. Rest is crucial in the first 24-48 hours.
B. Elevating the ankle helps reduce swelling and promotes venous return, which is important for managing an acute sprain.
C. Applying a compression bandage helps control swelling and provides support to the injured area. It is important to ensure that the bandage is not too tight, as this can impair circulation.
D. Heat is generally not recommended in the acute phase of an injury, as it can increase swelling and inflammation. Ice is preferred in the first 24-48 hours to reduce inflammation and pain.
E. Encouraging rest is essential to allow the ankle to heal and prevent further injury. Movement or activity can exacerbate the sprain and prolong recovery.

A. Request an order for an antiemetic. B. Request a dietitian consult. C. Check the client's vital signs. D. Suggest that the client rests before eating the meal.

Correct Answer is C

Explanation

A. While nausea and weakness could be related to a variety of factors, including gastrointestinal upset, requesting an antiemetic is not the first priority. The nurse must first assess the client's condition to determine if there is a more urgent issue, such as digoxin toxicity.
B. A dietitian consult may be helpful later, but it is not the first action. The nurse should first assess the client’s current physical condition.
C. The first action should be to check the client's vital signs. Nausea and weakness are common symptoms of digoxin toxicity, which can cause bradycardia, arrhythmias, and other life-threatening complications. Checking the vital signs, particularly the heart rate, is critical to assess if the client is experiencing digoxin toxicity.
D. While resting might help the client feel better, it does not address the potential underlying cause of the symptoms, such as digoxin toxicity, which should be evaluated first.

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A nurse is admitting a client who reports chest pain. Exhibits The nurse is preparing the client for the cardiac catheterization. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an acute ankle sprain. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?

Correct Answer is C

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A nurse is admitting a client who reports chest pain.

Exhibits

The nurse is preparing the client for the cardiac catheterization. Which of the following actions should the nurse take? (Select all that apply.)