A nurse is reviewing the client's diagnostic results and vital signs.

Exhibits

Which of the following actions should the nurse take? Select all that apply.

Anticipate client to be prepped for cardiac catheterization.

Assist with a continuous heparin infusion.

Encourage the client to ambulate.

Anticipate an increased dosage of metoprolol.

Obtain a prescription for client to be NPO.

Request a prescription for an antibiotic.

Answer and Explanation

Correct Answer : A,B,D,E

Chest pain radiating to the left arm is characteristic for angina in coronary artery disease. This is suggested more by the client’s medical history of hypertension, hyperlipidemia and type 2 diabetes mellitus.

Clients with angina are scheduled for diagnostic cardiac catheterization to assess the extent of coronary blockage

Heparin is used to prevent the propagation of a clot that is formed on an unstable atherosclerotic plaque. Beta blockers are prescribed to lower the heart rate. This reduces the myocardial demand for oxygen.

The firstline medication include antiplatelets unless there's concurrent venous thromboembolism.

Keeping the client NPO within 2 hours of the procedure is important to prevent aspiration whole under sedation.

Ambulation increases demand on the heart which may worsen the pain Antibiotics have no role in coronary artery disease.

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Correct Answer is C

Explanation

A. Monitoring of vital signs should be more frequent

B. This is an important infection control measure for immunocompromised clients. However, this is more about environmental control and may not directly address the specific isolation protocols regarding direct person-to-person transmission.
C. Wearing an N95 respirator may be recommended for direct care, especially if there is concern about exposure to airborne infections from the environment, staff, or visitors.
D. While disposable plates and utensils are generally preferred for infection control, this is not a specific intervention for protective isolation.

A. Use moisturizing lotion while massaging the client's bony prominences. B. Instruct the client to sit on a rubber ring when seated in a chair. C. Place pillows between the client's knees when in a side-lying position. D. Raise the head of the client's bed to a 90° angle.

Correct Answer is C

Explanation

C. Placing pillows between the client's knees when in a side-lying position helps maintain proper alignment of the hips and prevents the affected leg from crossing over the midline, which could lead to muscle
contractures or discomfort. It also helps prevent pressure on bony prominences and reduces the risk of skin breakdown.
A. Keeping the bony prominences too moist could lead to increased risk of skin breakdown.
B. This is not recommended as it could exacerbate muscle weakness or discomfort on the affected side and may not provide adequate support for proper alignment.
D. Raising the head of the bed to a 90° angle is not typically indicated for clients with hemiplegia. It may increase the risk of aspiration

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A nurse is reviewing the client's diagnostic results and vital signs.

Exhibits

Which of the following actions should the nurse take? Select all that apply.