Exhibits

A nurse is reviewing the client's diagnostic results and vital signs. Which of the following actions should the nurse take?

Anticipate client to be prepped for cardiac catheterization.

Assist with a continuous heparin infusion.

Encourage the client to ambulate.

Anticipate an increased dosage of metoprolol.

Obtain a prescription for client to be NPO.

Request a prescription for an antibiotic.

Answer and Explanation

Correct Answer : A,B,E

A.   The client presents with symptoms and signs suggestive of acute coronary syndrome, including chest pain, tachycardia, and ECG changes (ST segment elevation and T wave changes). Elevated troponin levels indicate myocardial injury. Cardiac catheterization is typically indicated in acute coronary syndrome to assess coronary artery anatomy and potentially perform interventions like angioplasty or stenting to restore blood flow to the heart muscle.
B.   Continuous heparin infusion is commonly used in the management of acute coronary syndrome to prevent further clot formation and stabilize the condition. It helps in reducing the risk of thrombus formation in the coronary arteries, which is crucial in cases of myocardial infarction.
C.   Ambulation is generally not recommended during the acute phase of myocardial infarction or unstable angina. The client's symptoms, such as chest pain, shortness of breath, and diaphoresis, indicate ongoing cardiac compromise. Ambulation could potentially worsen the client's condition or lead to adverse events.
D.   Metoprolol is a beta-blocker used to reduce heart rate, blood pressure, and myocardial oxygen demand. While it is indicated in acute coronary syndrome to stabilize heart rate and reduce myocardial ischemia, increasing the dosage should be done cautiously and based on the client's response to initial therapy.
E.   NPO status is typically indicated for clients undergoing procedures that require sedation or anesthesia, such as cardiac catheterization. It ensures the client's stomach is empty to reduce the risk of aspiration during the procedure. Given the potential need for cardiac catheterization in this client, obtaining a prescription for NPO status would be appropriate to prepare for the procedure and ensure safety.
F.   Antibiotics are not routinely indicated in the management of acute coronary syndrome unless there is evidence of concomitant infection or specific clinical indications (e.g., pneumonia). In the absence of signs or symptoms of infection, requesting an antibiotic prescription is not warranted based on the client's current presentation.

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Correct Answer is C

Explanation

C. A bed alarm is a device that triggers an alert when the client attempts to get out of bed or leaves a designated area. Bed alarms can be effective in alerting nursing staff to the client's movements, allowing for timely intervention to prevent wandering and ensure the client's safety. This intervention is commonly used in healthcare settings to monitor clients at risk for falls or wandering.

A Moving the client to a double room may not necessarily prevent wandering. In fact, it could potentially increase the risk if the client wanders into another resident's space or attempts to leave the room altogether.

B. Using chemical restraints (such as medications to sedate or calm the client) is not recommended unless absolutely necessary for the safety of the client or others. It does not address the underlying cause of wandering and can have significant adverse effects on the client's health and well-being.

D. Providing excessive stimulation can overwhelm and agitate clients with dementia, potentially worsening behaviors such as wandering. It is important to offer activities that are calming, engaging, and appropriate for the client's cognitive abilities.

A. Kussmaul respirations B. Increased urine output C. Cool, clammy skin D. Acetone breath

Correct Answer is C

Explanation

C. Cool, clammy skin is a common symptom of hypoglycemia. When blood sugar levels drop too low, the body's sympathetic nervous system is activated, causing sweating and cool, clammy skin as a response to the stress of low blood sugar.

A Kussmaul respirations are deep, rapid, and labored breathing patterns that occur in response to diabetic ketoacidosis (DKA), a complication of hyperglycemia rather than hypoglycemia. In hypoglycemia, the body typically responds with normal or shallow respirations.

B Increased urine output (polyuria) is more commonly associated with hyperglycemia, where the kidneys try to excrete excess glucose through urine. Hypoglycemia typically does not cause increased urine output.

D. Acetone breath, which has a fruity odor, is associated with diabetic ketoacidosis (DKA), a condition caused by severe hyperglycemia and metabolic acidosis. It is not a typical finding in hypoglycemia.

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Exhibits A nurse is reviewing the client's diagnostic results and vital signs. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Exhibits

A nurse is reviewing the client's diagnostic results and vital signs. Which of the following actions should the nurse take?