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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Lowering the bed height reduces the risk of injury in case the client falls out of bed. It also facilitates easier transfers for clients with mobility issues.
A Individuals with dementia may experience disorientation and confusion, especially in unfamiliar or dark environments. Turning off all lights can increase the risk of falls and accidents.
B. Clients with dementia may have difficulty recognizing the need to toilet or may forget where the bathroom is located. They may also have urinary or fecal incontinence. Scheduled toileting helps prevent accidents and promotes continence.
D. Sedatives or hypnotic medications can increase confusion, risk of falls, and adverse effects in older adults with dementia. They are generally not recommended as first-line treatment for sleep disturbances in dementia.
Correct Answer is B
Explanation
A Furosemide is likely to cause hypotension rather than hypertension.
B. Limiting salt intake is highly recommended while on furosemide because excess sodium can cause the body to retain water, which can worsen fluid retention and undermine the effectiveness of the diuretic.
C. Checking the pulse is important for certain medications that can affect heart rate, like beta-blockers. However, furosemide is not typically associated with major effects on pulse rate.
D. While increasing potassium-rich foods such as cantaloupe can be beneficial in managing electrolyte balance, it does not specifically address a potential adverse effect of the medication.
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