How it Works
Try Naxlex NCLEX-RN (Free-Trial)

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.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is C,D,A,B

Explanation

Rationale:

  • Apply clean gloves: Wearing clean gloves is the first step to maintain standard precautions and prevent contamination during specimen collection.
  • Swab the wound in a zig-zag manner: This technique ensures that the swab collects cells and fluid from multiple areas of the wound, increasing the likelihood of detecting any microorganisms present.
  • Place the swab in the culture container: Immediately inserting the swab into the sterile container maintains the integrity of the specimen and prevents contamination.
  • Ensure the container is labeled with the date and time of collection: Labeling the specimen is critical for accurate identification and processing by the lab. It must be done after collection to ensure the label reflects the correct time and date.

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"A,B"}}

Explanation

Rationale:

  • Report of pain: Abdominal pain is common in both cirrhosis and viral hepatitis due to liver inflammation, capsule stretching, or complications like ascites. In hepatitis, pain is often acute and located in the right upper quadrant, while in cirrhosis, it may be more generalized or related to portal hypertension.
  • Eye sclera finding: Jaundice, noted as yellowing of the sclera, occurs in both conditions due to impaired bilirubin metabolism. In cirrhosis, it's due to chronic hepatocellular failure, while in viral hepatitis, it's from acute inflammation impairing bilirubin excretion.
  • Alcohol intake history: A 25-year history of heavy alcohol use is a strong risk factor for alcoholic cirrhosis. While alcohol use can worsen viral hepatitis, it is not a primary cause of viral hepatitis, which is due to infection with hepatitis viruses (A, B, C, etc.).
  • Report of energy level: Fatigue is a common symptom in both conditions due to impaired liver function, toxin accumulation, anemia, or systemic inflammation. In viral hepatitis, fatigue is often sudden and profound, while in cirrhosis, it is usually chronic and progressive.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register