A nurse is caring for 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":"B","dropdown-group-2":"B"}
After notifying the provider, the nurse should first administer oxygen at 2 L/min via nasal cannula and then administer sublingual nitroglycerin
Rationale
Administer oxygen at 2 L/min via nasal cannula
The client is experiencing shortness of breath and chest pain with a decrease in oxygen saturation (92%), which is a concern, indicating that the client may be experiencing an acute cardiovascular event such as a myocardial infarction (MI). Administering oxygen helps to increase the oxygen supply to the heart and other vital organs.
Administer sublingual nitroglycerin
Nitroglycerin is a vasodilator that can help relieve chest pain associated with conditions like angina or myocardial infarction by increasing blood flow to the heart and reducing myocardial oxygen demand. The client’s pain level has increased to 7/10 on the pain scale, which suggests the chest pain may be related to an acute cardiac event.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The health care surrogate (a person authorized to make decisions on behalf of the client) must be informed of the risks and benefits of the procedure and provide consent.
B. Sending the consent form to the risk manager does not address the immediate need for informed consent from the surrogate.
C. While the family may be involved in decision-making, it is the health care surrogate who must provide consent.
D. The nurse should ensure the procedure is medically necessary, but obtaining informed consent is the priority.
Correct Answer is B
Explanation
A. While urine output is important, it is not the most direct indicator of the success of a paracentesis.
B. Comparing the client's weight before and after the procedure helps to evaluate the effectiveness by showing a reduction in fluid buildup.
C. Leakage at the site could indicate a complication, but it is not the primary measure of the procedure’s
effectiveness.
D. Serum albumin levels may be monitored but are not the first indicator of success after a paracentesis.
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