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A nurse is assisting with the care of a client.

Complete the following sentence by using the lists of options.

After notifying the provider, the nurse should first

and then

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

  • request a prescription for an increase in statin medication: Although the client's total cholesterol is elevated at 230 mg/dL, adjusting lipid management is not the immediate priority during an acute chest pain episode. The immediate focus should be stabilizing airway, breathing, and circulation.
  • prepare the client for cardiac catheterization: Cardiac catheterization may ultimately be needed to assess coronary artery blockages, but before this, the client must be stabilized with oxygen and medications to control chest pain and improve oxygenation.
  • administer oxygen at 2 L/min via nasal cannula: The client’s oxygen saturation dropped to 92% on room air, which is low for someone experiencing chest pain and possible myocardial ischemia. Administering supplemental oxygen improves myocardial oxygen supply and reduces cardiac workload, addressing airway and breathing priorities.
  • check a STAT cardiac troponin: The client’s initial troponin level was normal, but troponin can take several hours to rise after myocardial injury. While monitoring serial troponins is important, managing oxygenation and chest pain relief takes precedence right now.
  • administer sublingual nitroglycerin: After ensuring oxygenation, sublingual nitroglycerin should be administered to relieve chest pain by dilating coronary arteries and decreasing myocardial oxygen demand. It helps reduce ischemia and may prevent further cardiac injury.
  • request a prescription for a beta-blocker: Beta-blockers help control heart rate and blood pressure but are not the immediate first-line response for active chest pain and oxygen desaturation. Oxygen and nitroglycerin must be prioritized first to address the acute ischemic event.


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Related Questions

Correct Answer is A

Explanation

A. Take vital signs on clients as they are admitted: Taking vital signs is within the scope of practice for assistive personnel (AP) and is an essential task during a mass casualty event. It provides critical baseline information that the licensed staff can use to prioritize care and identify urgent needs.

B. Respond to family members about a client's condition: Communicating about a client's medical condition requires clinical judgment and is the responsibility of licensed nursing staff or healthcare providers. APs are not trained or authorized to give out clinical information to family members.

C. Clean and dress client abdominal wounds: Wound care, especially for open or surgical wounds like those on the abdomen, involves assessment and sterile technique, which must be performed by licensed personnel, not assistive personnel.

D. Determine which clients should be seen first: Determining client priority, also known as triage, requires nursing knowledge, critical thinking, and clinical assessment skills. It is a responsibility that falls to licensed nurses, not assistive personnel.

Correct Answer is C

Explanation

A. A client who requires sterile dressing changes every three hours: Sterile dressing changes require skilled nursing care and must be performed by a licensed nurse. An assistive personnel (AP) is not trained or authorized to perform sterile procedures, making this assignment inappropriate.

B. A client who has a small bowel obstruction and requires insertion of a nasogastric tube: Inserting a nasogastric tube is an invasive procedure that requires clinical judgment and proper technique, which are responsibilities of licensed nursing staff, not assistive personnel.

C. A client who is postoperative and requires intake and output measurement every 2 hr: Measuring and recording intake and output is within the scope of practice for assistive personnel. It is a routine, noninvasive task that does not require nursing assessment or judgment.

D. A client on hospice who is unstable and requires frequent vital sign checks: An unstable hospice client requires close monitoring and clinical assessment. Although assistive personnel can measure vital signs, evaluating changes and determining their significance must be done by licensed nursing staff.

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