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 first
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I think you should find other family members who could help your mother." While involving other family members can be helpful, this response may come across as dismissive rather than supportive. The nurse should offer specific resources or interventions to assist with caregiver burden.
B. "Let me give you some information about respite care for your mother." Respite care provides temporary relief for caregivers by allowing trained professionals to care for the client. This helps reduce caregiver stress, prevents burnout, and allows the son to rest while ensuring his mother receives appropriate care.
C. "You should think about placing your mother in a long-term care facility." Suggesting placement in a facility without first assessing the son’s willingness or ability to continue caregiving may be inappropriate. The nurse should offer less drastic options, such as respite care, before discussing long-term placement.
D. "You owe it to your mother to take care of her now that she needs you." This statement could induce guilt and increase stress for the caregiver. The nurse should provide emotional support and resources rather than making the son feel obligated to provide care without assistance.
Correct Answer is C
Explanation
A. Clear rhinorrhea. Mild respiratory illnesses, such as a common cold with clear nasal discharge, do not contraindicate varicella vaccination. The immunization can still be administered unless the child has a moderate to severe illness with fever.
B. Medications for a cardiac anomaly. Having a congenital heart defect or taking cardiac medications does not typically contraindicate varicella vaccination. However, children on high-dose immunosuppressive therapy for heart conditions may need further evaluation before receiving live vaccines.
C. Chemotherapy treatments. Chemotherapy suppresses the immune system, increasing the risk of severe complications from live vaccines like varicella. Children undergoing chemotherapy should not receive live-virus vaccines until immune function has sufficiently recovered, as determined by a healthcare provider.
D. Two diarrhea stools in the last day. Mild, self-limiting diarrhea does not contraindicate vaccination. Only children with severe acute gastrointestinal illness should have vaccinations postponed until they recover.
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