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 A
Explanation
A White rice is low in potassium compared to the other options listed, making it a suitable choice for individuals on a low-potassium diet for CKD.
B. Baked potatoes, particularly with the skin, are high in potassium and should be avoided or consumed in very small portions by individuals with CKD who are on a low-potassium diet.
C. While yogurt provides protein and calcium, it is moderate in potassium content and should be consumed in moderation by those limiting potassium intake.
D. Peanut butter is moderate in potassium content. Two tablespoons of peanut butter contain around 200-250 mg of potassium.
Correct Answer is ["A","B","C","D","E","F","G"]
Explanation
Blood glucose 310 mg/dL (74 to 106 mg/dL)
The initial blood glucose level was 468 mg/dL, indicating severe hyperglycemia, likely due to diabetic ketoacidosis (DKA). The decrease to 310 mg/dL suggests that the insulin therapy is starting to bring the blood glucose levels down towards normal range. This reduction is a positive sign of response to treatment.
Client urinating 100 mL/hour
This indicates improved kidney function compared to the initial presentation where the client reported frequent urination and nausea. Adequate urine output (typically more than 30 mL/hour) is crucial in managing DKA as it signifies improved renal perfusion and clearance of ketones and glucose from the blood.
Client is tolerating soft diet and oral fluids
This indicates improvement in gastrointestinal function and resolution of nausea, which is consistent with the ondansetron administration for nausea control. It also suggests that the client's appetite and overall condition are improving.
Bilateral pedal pulses 2+
Initially, the pulses were 1+, indicating poorer peripheral perfusion. Bilateral pedal pulses becoming 2+ suggest improved circulation, likely due to the correction of acidosis and hydration status with fluid and electrolyte
Blood pressure
The improvement in the blood pressure indicates that the client is out of the dehydration state caused by DKA.
Pulse rate
Resolution of tachycardia is a good indicator of improved hydration status
Respiratory rate
The decrease in respiratory rate is an indicator of improving acidosis and resolution of Kussmaul breathing common in DKA.
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