A patient with a cardiac disorder is having increased premature ventricular contractions and feels "anxious" and short of breath. After vital signs are obtained, what actions should the nurse take? Select all that apply.
Notify the health-care provider.
Start oxygen at 2 L/min.
Order an electrocardiogram and cardiac enzymes.
Place bed in modified Trendelenburg position.
Allow the patient to rest alone.
Elevate the head of the bed.
Correct Answer : A,B,C,F
A. Increased premature ventricular contractions along with symptoms of anxiety and shortness of breath may indicate worsening cardiac function or an acute cardiac event, necessitating immediate medical attention.
B. Oxygen therapy may help alleviate symptoms of shortness of breath and improve oxygenation in patients experiencing cardiac symptoms.
C. These diagnostic tests can provide valuable information about cardiac function and any potential myocardial damage or ischemia, helping guide further treatment and management.
D. The modified Trendelenburg position may increase cardiac workload, which is not beneficial in the case of PVCs.
E. The patient should not be left alone due to the need for ongoing assessment and potential rapid intervention. Furthermore, leaving them alone could worsen their anxiety.
F. Elevating the head of the bed can aid in breathing and comfort, reducing the sensation of breathlessness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
Bleeding: The client's platelet count has dropped from 160,000/mm³ to 100,000/mm³, which is below the normal range (150,000 to 400,000/mm³). Platelets are essential for blood clotting, and a low count increases the risk of bleeding. Additionally, the prolonged PT (13.5 seconds) and elevated INR (2.2) further indicate a tendency toward bleeding.
Infection: The client's WBC count remains elevated at 15,500/mm³, which can be indicative of ongoing infection or inflammation. Patients with acute leukemia often have dysfunctional white blood cells, which impairs their ability to fight infections effectively.
Correct Answer is C
Explanation
A. Daily weight monitoring is important for assessing fluid status but may not provide real-time information about fluid balance changes.
B. Vital signs are important for overall assessment but may not specifically address the nursing diagnosis of Excess Fluid Volume unless there are significant changes indicative of fluid overload or dehydration.
C. Monitoring intake and output provides direct information about fluid balance and renal function, helping to identify trends and assess the effectiveness of interventions aimed at managing fluid volume.
D. Skin turgor assessment is useful for evaluating hydration status but may not provide comprehensive data on fluid volume excess alone.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.