A patient has intra-arterial (art-line) blood pressure monitoring after a myocardial infarction (MI). Following the angioplasty procedure, the nurse notes that the patient's heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate?

Medicate the patient for pain.

Allow the patient to rest quietly.

Assess the patient for bleeding.

Document the findings in the chart.

Answer and Explanation

The Correct Answer is C

Choice A reason: Medicating the patient for pain is not the most appropriate immediate action in this situation. While pain management is important, the primary concern should be addressing the significant changes in heart rate and blood pressure, which may indicate a more serious underlying issue.

Choice B reason: Allowing the patient to rest quietly is not the appropriate response to the noted changes in vital signs. The increase in heart rate and drop in blood pressure are signs that require immediate investigation and intervention, rather than passive observation.

Choice C reason: Assessing the patient for bleeding is the most appropriate action. The increase in heart rate and decrease in blood pressure following an angioplasty procedure are concerning for potential bleeding or hemorrhage, especially if the patient has an intra-arterial line. Quick assessment and intervention are crucial to address any bleeding and stabilize the patient's condition.

Choice D reason: Documenting the findings in the chart is necessary, but it should not be the immediate priority. The nurse must first assess and address the potential cause of the changes in vital signs, such as bleeding, before documenting the events.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason: Providing at least 5000 kcal/day is essential for a patient with burn injuries. Burns significantly increase the body's metabolic rate and caloric needs to support the healing process and prevent catabolism. Ensuring an adequate caloric intake helps meet the energy demands required for tissue repair and recovery.

Choice B reason: Starting an oral diet on the first day may not be appropriate for all burn patients, particularly those with extensive burns or those who are not yet stable. Nutrition needs should be carefully assessed, and feeding may begin via alternative methods such as enteral nutrition until the patient is ready for oral intake.

Choice C reason: Administering a diet high in protein is crucial for burn patients, as protein is essential for wound healing, maintaining lean body mass, and supporting the immune system. Protein intake should be increased to help repair damaged tissues and promote recovery.

Choice D reason: Collaborating with a registered dietitian is important to create an individualized nutrition plan that meets the specific needs of the burn patient. A dietitian can provide expertise in calculating caloric and protein requirements, recommending appropriate supplements, and monitoring the patient's nutritional status.

Choice E reason: Offering frequent high-calorie snacks helps ensure that the patient meets their increased caloric needs. Small, frequent meals and snacks can be more manageable for patients with reduced appetite or those who have difficulty consuming large meals. High-calorie snacks provide additional energy to support healing and recovery.

A. Respiratory compromise. B. Stress ulcer. C. Paralytic ileus. D. Spinal shock.

Correct Answer is A

Explanation

Choice A reason: Respiratory compromise is the greatest risk for a client with a C4 spinal cord injury. The C4 spinal level is critical for the function of the diaphragm, which is the main muscle responsible for breathing. Injury at this level can impair diaphragmatic function, leading to difficulty in breathing or even respiratory failure. Immediate and continuous monitoring of respiratory status is essential for these patients to ensure adequate ventilation and oxygenation.

Choice B reason: Stress ulcers can develop in patients with spinal cord injuries due to the stress response and immobility. However, they are not the highest immediate risk compared to respiratory compromise, which can be life-threatening if not promptly addressed.

Choice C reason: Paralytic ileus, a condition where the intestines stop moving, can occur in spinal cord injury patients due to disruption of the nervous system control of the gut. While it is a significant concern, it is not as immediately life-threatening as respiratory compromise.

Choice D reason: Spinal shock is a condition that can occur after a spinal cord injury, leading to temporary loss of reflexes below the level of the injury. While it is an important condition to recognize and manage, the most urgent risk for a patient with a C4 injury is respiratory compromise due to the potential impact on breathing.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse plans care for a patient with burn injuries. Which interventions would the nurse include in this patient's plan of care to ensure adequate nutrition? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

A nurse is caring for a client who has a C4 spinal cord injury. Which of the following should the nurse recognize the client as being at the greatest risk for?

Correct Answer is A

Explanation

In a patient with septic shock, which complication will the nurse remain alert for?

The nurse has completed an assessment on a client with heart failure and a decreased cardiac output with an ejection fraction of 30%. Which finding should receive the highest priority?

A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following cues should the nurse assess to determine if the client is experiencing a myocardial infarction? Pick 2 answers.

Following paracentesis, during which 2500 mL of fluid was removed, which assessment finding is most important to communicate to the healthcare provider (HCP)?

The nurse is caring for a mechanically ventilated spinal cord injury patient in the ICU. To avoid the complication of autonomic dysreflexia, the nurse plans to implement the following orders: Select all that apply.

A nurse in the emergency room is performing an assessment on a burn victim. She notes his face is a cherry-red color and suspects which of the following problems?

A patient is unsure of the decision to undergo peritoneal dialysis (PD) and wishes to discuss the advantages of this treatment with the nurse. Which statements by the nurse are accurate regarding PD? Select all that apply.

The nurse is caring for a patient admitted with advanced liver disease. Which laboratory result(s) would the nurse expect? Select all that apply.