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The nurse is continuing to care for the client following updates to the Nurses' Notes, Vital Signs, and Diagnostic Results.

Exhibits

Complete the following sentence by using the lists of options.

The nurse should first address the client's

followed by the client's

Answer and Explanation

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.


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Related Questions

Correct Answer is D

Explanation

Rationale:
A. Place the affected leg in external rotation: External rotation of the leg can increase the risk of hip dislocation following a total hip arthroplasty. The leg should be maintained in a neutral or slightly abducted position to protect the joint.

B. Encourage the client to use the incentive spirometer every shift: Incentive spirometry should be used every 1 to 2 hours while awake to prevent postoperative complications like atelectasis. Using it only once per shift is not sufficient.

C. Instruct the client to lean forward when rising from a chair: Leaning forward while rising increases hip flexion beyond 90 degrees, which places stress on the hip joint and raises the risk of dislocation. Clients should keep their hips higher than their knees and use armrests for support.

D. Maintain abduction of the affected extremity: Keeping the leg in abduction helps prevent dislocation of the prosthetic joint by maintaining proper alignment. This can be achieved using an abduction pillow or wedge between the legs.

Correct Answer is B

Explanation

Rationale:
A. Use an infusion pump to deliver the dialysate at a safe rate: Dialysate for peritoneal dialysis is typically instilled by gravity, not an infusion pump. Using a pump can create excessive pressure, increasing the risk of peritoneal damage or discomfort.

B. Report cloudy dialysate drainage to the provider: Cloudy outflow is a key sign of peritonitis, a serious complication of peritoneal dialysis. This finding should be reported immediately for prompt evaluation and treatment.

C. Warm the dialysate solution using a low power level on a microwave oven: Dialysate should not be warmed in a microwave due to the risk of uneven heating and potential damage to the peritoneal lining. A warming pad or commercial dialysate warmer is recommended to safely bring the solution to body temperature.

D. Allow the dialysate to drain over 1 to 4 hr: The dwell time (the time the dialysate stays in the peritoneal cavity) typically ranges from 30 minutes to a few hours. However, the drainage phase should usually take about 15 to 30 minutes. Allowing dialysate to drain over 1 to 4 hours would be incorrect, as this refers more to dwell time, not the drainage phase.

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