A nurse is caring for a 65-year-old male client in the emergency department. The client is presenting with symptoms of a potential cardiac event and has been admitted for further evaluation.
Complete the following sentence by selecting the most appropriate actions based on the client’s current status.
The nurse should first
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
The nurse should first: Response 1: Notify the primary health care provider immediately.
This is crucial because the client is showing signs of a potential cardiac event, which requires immediate medical attention.
Then, the nurse should: Response 2: Start an IV line for potential medication administration.
Starting an IV line ensures that the client can receive any necessary medications quickly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Ulcerative colitis often results in inflammation and ulcers in the colon lining, which can lead to bleeding and a positive fecal occult blood test. This is a common complication of the condition.
Choice B rationale
Cholecystitis, an inflammation of the gallbladder, does not typically cause gastrointestinal bleeding or a positive fecal occult blood test. It is more associated with abdominal pain and digestive issues.
Choice C rationale
The use of laxatives generally does not cause internal bleeding that would result in a positive fecal occult blood test. Laxatives are more likely to cause changes in bowel habits and diarrhea.
Choice D rationale
Stomatitis, inflammation of the mouth, is unlikely to cause a positive fecal occult blood test. It primarily affects the oral cavity and is not associated with gastrointestinal bleeding. .
Correct Answer is B,A,C,D,E
Explanation
Choice A rationale
Unlocking and removing the inner cannula is the first step. It allows access to the inner cannula for cleaning and ensures that the tracheostomy tube remains patent.
Choice B rationale
Pouring 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin provides the necessary solution for cleansing the inner cannula and stoma site, helping to maintain sterility and prevent infection.
Choice C rationale
Scrubbing the inside and outside of the inner cannula with a small brush ensures that any mucus or debris is removed, reducing the risk of infection and maintaining clear airways.
Choice D rationale
Wiping the inside of the inner cannula with a folded pipe cleaner helps to remove any remaining debris or solution, ensuring that the inner cannula is thoroughly cleaned.
Choice E rationale
Cleansing the stoma site with 0.9% sodium chloride solution helps to remove any mucus or debris from the site, maintaining hygiene and reducing the risk of infection.
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