A nurse receives the following medication orders while caring for multiple clients. Which medication should the nurse plan to administer first?
Normal saline 1 liter to client who is dehydrated
Morphine sulfate 4mg intravenously (IV) now for the client experiencing incisional pain
Nitroglycerin (Nitrostat) 0.4 mg sublingually (SL) stat for the client experiencing crushing chest pain
Lorazepam 2 mg IV now for the client who is anxious and restless
The Correct Answer is C
A) Normal saline 1 liter to client who is dehydrated:
Administering normal saline to a dehydrated client is an important task, as it helps to restore fluid balance and improve circulatory volume. However, while rehydration is critical, it is not an immediate, life-threatening priority compared to other interventions. The nurse should begin this infusion after addressing more urgent needs such as severe chest pain, which could indicate a cardiac emergency.
B) Morphine sulfate 4mg intravenously (IV) now for the client experiencing incisional pain:
Morphine is a potent analgesic, and relieving pain for postoperative patients is essential for comfort and recovery. However, incisional pain, although important to address, is not life-threatening in this scenario. The client with chest pain should be prioritized because chest pain could indicate a myocardial infarction (MI) or other serious cardiac event that requires immediate intervention.
C) Nitroglycerin (Nitrostat) 0.4 mg sublingually (SL) stat for the client experiencing crushing chest pain:
Crushing chest pain is a classic symptom of acute myocardial infarction (MI), a life-threatening condition that requires immediate intervention. Nitroglycerin is used to relieve chest pain associated with angina or MI by dilating the coronary arteries and improving blood flow to the heart. In this case, chest pain is the most critical symptom, and immediate treatment is necessary to reduce the risk of further cardiac damage or complications.
D) Lorazepam 2 mg IV now for the client who is anxious and restless:
While lorazepam is an effective medication for anxiety and restlessness, it is not the most urgent medication in this case. The client’s anxiety should be addressed, but it does not pose an immediate threat to life. Anxiety can generally be managed after more acute, life-threatening conditions (such as chest pain) are stabilized.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) The time between ventricular depolarization and repolarization (diastole):
This refers to the period between ventricular depolarization and repolarization, which is associated with the QT interval on the EKG, not the P wave. The P wave specifically relates to atrial depolarization, not the ventricular activity. Diastole refers to the relaxation phase of the heart cycle, and it’s not directly linked to the P wave, which represents atrial contraction.
B) Time taken for impulse to spread to the point immediately preceding ventricular contraction:
The P wave represents the depolarization (or contraction) of the atria, not the time taken for the impulse to spread to the ventricles. The time taken for the impulse to spread through the atria, across the AV node, and down to the ventricles is better represented by the PR interval, not the P wave itself.
C) Time taken for depolarization (contraction) of both ventricles (systole):
This describes the QRS complex, which represents the depolarization (contraction) of the ventricles during systole, not the P wave. The QRS complex shows the electrical activity of the ventricles as they contract, while the P wave relates to atrial depolarization, which occurs before ventricular contraction.
D) Passage of electrical impulse through the atrium causing atrial depolarization:
The P wave represents the passage of the electrical impulse through the atria, leading to atrial depolarization. Depolarization of the atria results in the contraction of the atria, pushing blood into the ventricles. The P wave is the first part of the cardiac cycle on the EKG and reflects the electrical activity that causes atrial contraction.
Correct Answer is D
Explanation
A. Hypertension:
Hypertension is not directly related to the rhythm displayed in the image. The rhythm is suggestive of atrial fibrillation (AF), characterized by irregular and chaotic electrical activity, leading to irregular heartbeats. Hypertension can be a risk factor for AF but is not a typical presenting symptom.
B. Indigestion:
Indigestion is a non-specific symptom that may occur in cardiac events like myocardial infarction but is not a hallmark of atrial fibrillation. The rhythm strip does not indicate myocardial ischemia.
C. Eupnea:
Eupnea refers to normal breathing, which is not commonly associated with atrial fibrillation. Clients with AF may experience symptoms such as shortness of breath or fatigue rather than normal, unlabored breathing.
D. Irregular palpitations:
This is the most expected finding. Atrial fibrillation leads to an irregularly irregular pulse, which patients often describe as palpitations. This rhythm strip demonstrates the hallmark chaotic atrial activity and irregular ventricular response seen in AF.
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