A nurse is assisting with the care of a client.
Complete the following sentence by using the list of options. After notifying the provider, the nurse should and then
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
After notifying the provider about the client's condition, the immediate actions should focus on managing the client's chest pain and potential cardiac event.
Administering oxygen at 2 L/min via nasal cannula helps ensure adequate oxygenation, while administering sublingual nitroglycerin helps alleviate chest pain and improve blood flow to the heart. The incorrect options do not address the immediate needs of a client experiencing chest pain and potential myocardial ischemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Furosemide is a loop diuretic that helps eliminate excess fluid and sodium from the body by increasing urine production. Increased urinary output is an indication that the medication is effectively managing fluid overload, a common issue in heart failure.
B. Incorrect. While a decreased BUN (blood urea nitrogen. level might occur due to improved kidney function, it is not a direct indicator of furosemide's effectiveness.
C. Incorrect. An increased weight suggests fluid retention, which would not indicate the effectiveness of furosemide.
D. Incorrect. Decreased hemoglobin levels may be due to various factors and are not directly related to the effectiveness of furosemide.
Correct Answer is B
Explanation
A.Restraints should be released more frequently, typically every 2 hours, to assess circulation, skin integrity, and range of motion, and to provide an opportunity for toileting and other needs.
B.It is essential to document the specific behaviors that led to the use of restraints, as this provides a clear rationale for why the restraints were necessary. This documentation is important for legal and clinical reasons and helps ensure that restraints are used appropriately and only when absolutely necessary.
C.Clients are not required to provide written consent for the use of restraints, especially in situations where restraints are necessary to protect the client or others from immediate harm. However, the nurse must follow the facility's protocol, which usually involves obtaining a physician's order and documenting the justification for the restraint use.
D.The nurse should check the client's status more frequently, typically every 15 minutes, to ensure the client's safety and well-being while in restraints.
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