A nurse on a step-down unit is admitting a client.
Complete the following sentence by using the lists of options.
The nurse should first
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Rationale for correct choices:
- Apply oxygen via nasal cannula: The client’s oxygen saturation levels of 87–88% on room air indicate moderate to severe hypoxemia, requiring immediate correction. Since the client has a history of COPD and is post-MI, improving oxygenation is essential to reduce myocardial workload and prevent further ischemia or respiratory distress.
- Initiating a consult for cardiac rehabilitation: Once the client's immediate needs are stabilized, early initiation of cardiac rehabilitation is appropriate. This supports physical recovery, promotes lifestyle changes like smoking cessation and exercise, and reduces future cardiac risk.
Rationale for incorrect choices:
- Administer a second dose of nitroglycerin: The client’s chest pain has resolved following the initial dose, so there is no current indication to give a second dose. Re-administering nitroglycerin unnecessarily can lead to hypotension or reflex tachycardia, especially risky in a post-MI patient.
- Request a prescription for a PRN anxiolytic: The client has already been prescribed alprazolam 0.5 mg three times daily, and their anxiety has improved. Requesting an additional anxiolytic is unnecessary at this point and does not address the more urgent issue of low oxygen saturation.
- Requesting a prescription for a WBC count: There are no signs or symptoms of infection such as fever, chills, or elevated WBC to justify this request. The focus should remain on the client’s cardiopulmonary status and rehabilitation rather than diagnostics that are not clinically indicated.
- Administering a bolus of fluids: There is no clinical indication of fluid volume deficit, hypotension, or dehydration. Administering fluids to a post-MI patient with COPD may lead to fluid overload, pulmonary edema, or increased myocardial strain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Monitor the client's vital signs every hour following the procedure: Vital signs, especially blood pressure, should be monitored more frequently—usually every 5 to 15 minutes immediately after epidural initiation—to assess for hypotension, a common complication.
B. Review the client's platelet count level prior to the procedure: A low platelet count increases the risk of epidural hematoma during needle insertion. Reviewing coagulation status is essential to ensure it's safe to proceed with epidural placement.
C. Inform the client that their bladder should be full before the procedure: The bladder should be emptied, not full, prior to the procedure. A full bladder increases discomfort, impairs fetal descent, and may lead to urinary retention after the epidural is placed.
D. Obtain the client's consent following the procedure: Informed consent must be obtained before any invasive procedure, including epidural anesthesia. Performing the procedure without prior consent violates patient autonomy and legal standards.
Correct Answer is C
Explanation
Rationale:
A. Document assessment findings and interventions after providing care for a group of clients: Delaying documentation can lead to inaccuracies or omissions due to forgetfulness. Real-time or immediate documentation ensures completeness and supports continuity of care.
B. Gather supplies for a client's dressing change after removing the old dressing: Supplies should be gathered in advance to minimize delays and reduce the risk of contamination or client exposure. Doing so afterward is inefficient and interrupts workflow.
C. Complete activities for one client before moving to the next client: Focusing on one client at a time improves efficiency, reduces errors, and supports prioritization. It allows for full attention on care tasks and appropriate time management across the shift.
D. Delay cleaning personal work area until the end of the shift: Maintaining a clean and organized workspace throughout the shift helps prevent errors, improves efficiency, and supports infection control, especially in high-traffic care areas.
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