Exhibits
Complete the following sentence by using the lists of options.
The nurse should first address the client
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).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D,B,A,C
Explanation
Step D (Place the client in an upright sitting position): Elevating the client's head and upper body to an upright position helps to reduce blood pressure by promoting venous pooling in the lower extremities.
Step B (Confirm that the client's bladder is empty): Autonomic dysreflexia is often triggered by bladder distention or urinary retention. By confirming and addressing urinary issues promptly, the nurse can remove the triggering stimulus.
Step A (Administer an antihypertensive medication intravenously): In severe cases where blood pressure remains dangerously high despite other interventions, such as positioning and addressing bladder issues, antihypertensive medications may be necessary to lower blood pressure quickly and prevent complications.
Step C (Indicate the risk for autonomic dysreflexia in the client's medical record): Documentation of the occurrence of autonomic dysreflexia, its triggers, and interventions used is essential for continuity of care. It informs other healthcare providers about the client's condition and helps in implementing preventive strategies.
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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