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Complete the following sentence by using the lists of options.

The nurse should first address the client

followed by the client's

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

The nurse should first address the client pain level followed by the client's ECG results

Rationale

Pain level: Addressing the client's pain level is crucial because it directly affects their comfort and can be indicative of ongoing myocardial ischemia or infarction. The client initially reported chest pain as 7/10, which is significant. Although it has decreased to 5/10 after nitroglycerin, ongoing assessment of pain is essential to ensure it does not worsen or change in nature.

ECG results: The 12-lead electrocardiogram (ECG) shows tachycardia with ST segment elevation and T wave changes. These findings indicate acute myocardial ischemia or infarction, which is a critical concern. The ECG results guide further diagnosis and treatment decisions, such as determining the need for immediate reperfusion therapy (like thrombolytics or angioplasty).


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Related Questions

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

Explanation

. Potassium chloride 20 mEq/L intravenous PRN potassium less than 5.0 mEq/L

The client's potassium level is slightly elevated at 5.5 mEq/L. Potassium replacement may be necessary if the level drops below 5.0 mEq/L, which is within the anticipated range for the nurse's actions.

D.0.9% sodium chloride at 15 ml/kg/hr for 1 hr and then reduce to 10 ml/kg/hr

This prescription addresses the need for fluid resuscitation to correct dehydration and electrolyte imbalances often seen in DKA. The client's initial blood pressure of 96/65 mm Hg suggests some degree of dehydration, further supporting the use of isotonic saline.

E.Regular insulin continuous infusion, titrate per diabetic ketoacidosis (DKA) protocol once potassium is greater than 3.3 mEq/L

This prescription aligns with the client's presentation of severe hyperglycemia (468 mg/dL) and acidosis (pH 7.30), indicating diabetic ketoacidosis (DKA). Insulin infusion is crucial for lowering blood glucose levels and correcting acidosis.

Correct Answer is B

Explanation

B. After a lumbar puncture, instructing the client to lie flat on their back for a period of time (often 1-2 hours) helps prevent complications such as headaches due to CSF leakage and promotes proper sealing of the puncture site.

A Monitoring blood glucose every 2 hours is not typically necessary immediately following a lumbar puncture unless the client has pre-existing diabetes or there are specific indications to monitor glucose levels

C Tingling in the extremities is not an expected or normal occurrence following a lumbar puncture. It could indicate neurological complications such as nerve irritation or damage, which would require prompt assessment and intervention.

D. The nurse should encourage adequate hydration unless contraindicated by the client's medical condition or specific post-procedure instructions.

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