The nurse is continuing to care for the client following updates to the Nurses' Notes, Vital Signs, and Diagnostic Results.
Complete the following sentence by using the lists of options.
The nurse should first address the client's
The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"E"}
Rationale:
- Elevated blood glucose: A random glucose level of 220 mg/dL is mildly elevated and can be expected during acute illness or stress, especially in clients with diabetes. It should be monitored but does not require immediate intervention in this cardiac context.
- Elevated heart rate: A heart rate of 116/min reflects tachycardia, which may result from pain, anxiety, or reduced cardiac output. While it is an important finding, it is secondary to more urgent issues like chest pain or myocardial injury.
- Epigastric discomfort: Epigastric discomfort alone is not an emergency finding and can occur in non-cardiac conditions such as GERD or peptic ulcer disease. While it may signal atypical angina, it lacks the specificity or urgency of active chest pain.
- Chest pain: Chest pain is a classic symptom of myocardial ischemia and warrants immediate intervention. The nurse should apply oxygen, initiate cardiac monitoring, assess pain characteristics, establish IV access, and prepare to administer nitroglycerin or aspirin per protocol.
- Elevated troponin: A troponin level of 10.15 ng/mL confirms myocardial injury and supports the diagnosis of myocardial infarction. The nurse should report this result immediately, anticipate further cardiac workup, continue ECG and vital monitoring, and prepare the client for possible transfer to a higher level of care.
- Elevated blood pressure: A BP of 158/92 mm Hg is elevated but not critical in this context. It is likely a response to pain or anxiety and can be managed after more urgent issues, such as ischemia or infarction, have been addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Asthma: Asthma affects the respiratory system and does not have a direct link to urinary tract infections. It does not alter urinary tract anatomy or immune defenses specific to the urinary system.
B. Diabetes mellitus: Clients with diabetes are at increased risk for UTIs due to immune suppression, glucosuria that promotes bacterial growth, and possible bladder dysfunction (e.g., urinary retention) from diabetic neuropathy. Poor glycemic control further raises infection susceptibility.
C. Pernicious anemia: This condition is related to vitamin B12 deficiency and affects red blood cell production and neurological function, but it does not specifically predispose clients to UTIs.
D. Osteoporosis: Osteoporosis involves reduced bone density and is not associated with urinary tract infections. It does not impact the urinary or immune systems directly.
Correct Answer is ["0.5"]
Explanation
Calculation:
Calculate the total desired dose in mg:
Desired dose (mg) = Weight (kg) x Ordered dose (mg/kg)
Desired dose (mg) = 69.9 kg x 0.75 mg/kg
Desired dose (mg) = 52.425 mg
Determine the volume to administer using the available concentration:
Volume to administer (mL) = Desired dose (mg) / Available concentration (mg/mL)
First, find the concentration in mg/mL:
60 mg / 0.6 mL = 100 mg/mL
Now, calculate the volume:
Volume to administer (mL) = 52.425 mg / 100 mg/mL
Volume to administer (mL) = 0.52425 mL
Round the answer to the nearest tenth:
0.52425 mL rounded to the nearest tenth is 0.5 mL.
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