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A nurse is assisting with the care of a client.

Exhibits

Complete the following sentence by using the list of options.

After notifying the provider, the nurse should first

and then
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

  • Administer sublingual nitroglycerin. Nitroglycerin is a first-line treatment for angina or suspected myocardial infarction. It dilates coronary arteries, improving blood flow and reducing myocardial oxygen demand.
  • Apply supplemental oxygen. Routine oxygen administration is no longer recommended unless the client is hypoxic (oxygen saturation below 90%) because excessive oxygen can lead to vasoconstriction and worsen myocardial injury.
  • Obtain a 12-lead ECG. While an ECG is important for diagnosing myocardial infarction, the priority in an acute chest pain episode is symptom relief and hemodynamic stability. The ECG should already have been obtained at admission.
  • Administer morphine sulfate IV. Morphine is used to manage severe chest pain that is not relieved by nitroglycerin. It reduces myocardial oxygen demand, preload, and anxiety, which can help relieve symptoms.
  • Monitor vital signs. Continuous monitoring is essential, but it is not the most immediate intervention in an acute episode of worsening chest pain. The focus should be on relieving ischemia and reducing myocardial workload.
  • Educate the client about smoking cessation. While smoking cessation is critical for long-term cardiovascular health, education is not a priority when the client is experiencing acute chest pain requiring immediate intervention.


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Related Questions

Correct Answer is A

Explanation

A. "I will get you information about some head-covering options." This response is supportive and addresses the client's concerns about hair loss in a practical way. Providing information about head coverings, such as hats, scarves, or wigs, can help the client feel more prepared and empowered to manage this aspect of their treatment.
B. "I wouldn't worry about this right now. Let's focus on your chemotherapy." Dismissing the client's concerns may make them feel invalidated. Hair loss can be a significant emotional issue for many clients undergoing chemotherapy, and it’s important to address their feelings and provide support.
C. "Let's discuss this when we have more time." Postponing the conversation may leave the client feeling anxious or unsupported. Clients may need immediate reassurance and resources regarding their concerns, so it is essential to address it in a timely manner.
D. "I can't imagine how difficult it would be to lose my hair." Expressing empathy is important, but shifting the focus to the nurse's feelings rather than addressing the client's concerns is not helpful. It is more beneficial to provide practical support and resources to help the client cope with potential hair loss.

Correct Answer is C

Explanation

A. "I should use my inhaler before exercising." Budesonide is an inhaled corticosteroid used for long-term asthma control, not for immediate prevention of exercise-induced bronchospasm. A short-acting beta-agonist (e.g., albuterol) should be used before exercise to prevent bronchospasm.
B. "I should use my inhaler when I have an asthma attack." Budesonide is not a rescue inhaler. It is used daily to reduce airway inflammation and prevent asthma exacerbations. During an acute asthma attack, a fast-acting bronchodilator, such as albuterol, should be used instead.
C. "I will rinse my mouth and gargle with water after each inhaler treatment." Rinsing the mouth after using an inhaled corticosteroid helps prevent oral candidiasis (thrush), a common side effect of steroid inhalers. This practice also reduces irritation and hoarseness associated with corticosteroid use.
D. "I will take my inhaler treatment before each meal and at bedtime." Budesonide is not taken on a strict schedule tied to meals or bedtime. It is usually administered once or twice daily, as prescribed, to maintain consistent anti-inflammatory effects.

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