A nurse is caring for a 58-year-old male client in the emergency department (ED) who presents with an irregular pulse and elevated blood pressure.
The nurse is planning care for the client. For each potential prescription, indicate whether it is indicated, nonessential, or contraindicated.
Administer O2 to maintain oxygen saturation greater than 90%.
Prepare the client for intubation.
Apply continuous ECG monitoring.
Obtain the client’s family history.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"}}
Rationales:
- Administer O2 to maintain oxygen saturation greater than 90%: This prescription is indicated. Hypoxia can exacerbate cardiac and respiratory issues, so it is essential to maintain adequate oxygen levels in the blood. Supplemental oxygen can help improve tissue oxygenation and reduce strain on the heart.
- Apply continuous ECG monitoring: This prescription is indicated. Continuous ECG monitoring is crucial in detecting arrhythmias and ischemic changes in a patient with cardiac symptoms and irregular pulse. Early detection allows for timely intervention and management of potentially life-threatening cardiac events.
- Obtain the client’s family history: This prescription is nonessential. While obtaining a family history is useful for identifying potential genetic predispositions to cardiac and metabolic conditions, it is not immediately necessary for the acute management of the client’s current symptoms.
- Prepare the client for intubation: This prescription is contraindicated. The client is currently maintaining an adequate respiratory rate and oxygen saturation on room air. There is no indication of respiratory failure or inability to maintain airway patency. Intubation would be an unnecessarily invasive procedure at this time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Flushed, warm legs are characteristic of chronic venous insufficiency, not peripheral artery disease, which results in poor arterial blood flow and cool extremities.
Choice B rationale
Thin, pliable toenails suggest nutritional deficiencies or fungal infections, not advanced peripheral artery disease, which often leads to thick, brittle nails.
Choice C rationale
Hairy legs are indicative of adequate blood flow. In peripheral artery disease, decreased blood flow results in hair loss on the legs.
Choice D rationale
Leg pain at rest, called rest pain, signifies advanced peripheral artery disease due to severe arterial insufficiency and poor oxygen supply to tissues. .
NGN QUESTIONS
Correct Answer is C
Explanation
Choice A rationale
A red and beefy tongue suggests nutritional deficiencies like iron or vitamin B12 deficiency, not digoxin toxicity.
Choice B rationale
Constipation is a gastrointestinal issue, commonly related to diet, fluid intake, or other medications, not an indicator of digoxin toxicity.
Choice C rationale
Digoxin toxicity often manifests as visual disturbances, such as yellow or blurred vision, due to its effect on the central nervous system.
Choice D rationale
Weight gain is not associated with digoxin toxicity but may result from other conditions such as hypothyroidism or fluid retention.
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