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.

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Correct Answer is B

Explanation

Choice A reason: The rehabilitative phase of burn care focuses on restoring function, improving cosmetic appearance, and achieving the best possible quality of life for the patient. This phase typically begins after the wound has healed and continues for months to years. The care priorities mentioned, such as wound care and nutritional support, indicate that the patient is still in a more active phase of treatment rather than the long-term rehabilitative phase.

Choice B reason: The acute phase of burn care starts after the initial resuscitation and continues until the wound is closed. During this phase, the primary focus is on wound care, nutritional support, and prevention of complications like infection. The goal is to promote healing, prevent infection, and address the patient's nutritional needs to support recovery. This phase aligns with the care priorities mentioned in the question.

Choice C reason: The emergent phase, also known as the resuscitative phase, begins at the time of injury and continues for the first 24-48 hours. The primary focus during this phase is on stabilizing the patient's condition, managing airway and breathing, fluid resuscitation, and addressing immediate life-threatening issues. The care priorities in the question indicate that the patient has moved beyond the initial resuscitative efforts.

Choice D reason: The immediate resuscitative phase overlaps with the emergent phase and focuses on providing immediate life-saving measures to stabilize the patient. This includes fluid resuscitation, airway management, and treating shock. The care priorities mentioned in the question suggest that the patient is beyond the initial resuscitative efforts and is in a more ongoing phase of treatment.

A. Place the client in a side-lying position. B. Administer hydromorphone for pain as prescribed. C. Obtain daily weights. D. Maintain a high-calorie, high-protein diet. E. Monitor the client's respiratory status.

Correct Answer is ["A","B","E"]

Explanation

Choice A reason: Placing the client in a side-lying position is beneficial for comfort and can help alleviate pain in clients with acute pancreatitis. This position can reduce pressure on the pancreas and improve circulation, helping to manage pain and discomfort effectively.

Choice B reason: Administering hydromorphone for pain as prescribed is essential in managing acute abdominal pain associated with acute pancreatitis. Pain control is a priority in the care of these clients because unmanaged pain can lead to increased stress and further complications. Hydromorphone, a potent opioid analgesic, helps to effectively manage severe pain.

Choice C reason: Obtaining daily weights is important for monitoring a client's nutritional status and fluid balance, but it is not directly related to the immediate management of acute abdominal pain in acute pancreatitis. While it is a relevant intervention, it is not as critical as the other measures listed.

Choice D reason: Maintaining a high-calorie, high-protein diet is not appropriate for a client with acute pancreatitis. In fact, clients with acute pancreatitis are often placed on a nil-per-os (NPO) status initially to rest the pancreas and reduce enzyme secretion. Once the inflammation subsides, a low-fat, bland diet may be introduced gradually.

Choice E reason: Monitoring the client's respiratory status is crucial because clients with acute pancreatitis are at risk for respiratory complications, such as pleural effusion, acute respiratory distress syndrome (ARDS), or atelectasis. Close monitoring ensures early detection and intervention for any respiratory issues that may arise.

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Naxlex Comprehensive Predictor Exams

The nursing care priorities for the patient with burn injuries include wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is most likely in which phase of burn care?

Correct Answer is B

Explanation

When providing care for a client hospitalized with acute pancreatitis who has acute abdominal pain, which nursing interventions would be most appropriate for this client? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

A patient with a spinal cord lesion at T4 tells the nurse that he has a headache and feels flushed. The blood pressure is significantly elevated to 190/100. The first action by the nurse is to:

Which specific drug therapy will the nurse anticipate for management of the client who has septic shock?

A nurse plans care for a patient with acute pancreatitis. Which intervention would the nurse include in this patient's plan of care to reduce discomfort?

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

A nurse is caring for a postoperative 70-kg patient who had major blood loss during surgery and now has acute kidney injury. The patient does not have signs of fluid overload. Which intervention would be most effective as a fluid challenge to promote kidney perfusion?

To improve the oxygenation of a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation, the nurse should place the client in which position?

In planning the care for a patient with acute pancreatitis, the nurse should make which of these goals the highest?

Which instruction would best reduce the symptoms of a client with heart failure and assure more comfort at home?