The nurse is reviewing the client's medical record.
A nurse is reviewing the client's diagnostic results and vital signs. Which of the following actions should the nurse take? Select all that apply.
Anticipate client to be prepped for cardiac catheterization.
Assist with a continuous heparin infusion.
Encourage the client to ambulate.
Anticipate an increased dosage of metoprolol.
Obtain a prescription for client to be NPO.
Request a prescription for an antibiotic.
Correct Answer : A,B,E
- Anticipate client to be prepped for cardiac catheterization: Given the client's diagnosis of myocardial infarction and persistent chest pain, cardiac catheterization may be necessary for evaluating coronary artery patency and determining the need for potential interventions such as angioplasty or stenting. Prepping the client for this procedure is appropriate.
- Assist with a continuous heparin infusion: Heparin is often used in acute coronary syndrome management to prevent thrombus formation and reduce the risk of further myocardial injury. Initiating a continuous heparin infusion may be indicated following an assessment of the client’s condition and provider orders.
- Encourage the client to ambulate: While early ambulation is important for recovery and preventing complications, in the acute phase of a myocardial infarction, clients should be closely monitored and may require bed rest initially. Encouraging ambulation should only occur once the client is stable and after consulting with the healthcare provider.
- Anticipate an increased dosage of metoprolol: Metoprolol is typically administered to manage heart rate and blood pressure, but the dosage should be based on the client’s current vital signs and response to treatment. If the client’s heart rate remains elevated or if there are signs of ongoing ischemia, an increased dosage may be necessary, but this should be based on provider orders rather than an automatic assumption.
- Obtain a prescription for client to be NPO: Clients scheduled for procedures such as cardiac catheterization often require NPO status to prevent aspiration during sedation. Additionally, if the client is experiencing nausea, keeping them NPO can prevent further complications.
- Request a prescription for an antibiotic: There is no indication of an infection or a need for antibiotic therapy. Antibiotics are typically not indicated for the management of myocardial infarction unless there is a concurrent infection. Therefore, requesting an antibiotic prescription is not appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Diminished breath sounds: A pneumothorax occurs when air accumulates in the pleural space, leading to lung collapse. This results in reduced air entry, causing diminished or absent breath sounds on the affected side. Other symptoms may include dyspnea, tachypnea, and chest pain.
B. Distended neck veins: Neck vein distention is more commonly associated with conditions such as cardiac tamponade or superior vena cava syndrome. A pneumothorax typically causes respiratory distress rather than venous congestion. If a tension pneumothorax develops, neck vein distention may occur, but it is not an early or primary sign.
C. Irregular heart rate: While severe cases of pneumothorax can cause cardiovascular compromise due to pressure on the heart and great vessels, an irregular heart rate is not a direct or early indicator. Cardiac arrhythmias are more often seen with electrolyte imbalances, cardiac ischemia, or other primary heart conditions.
D. Itching over the incision: Itching at the catheter insertion site is a common postoperative reaction, often related to healing, adhesive irritation, or mild inflammation. It is not indicative of a pneumothorax, which primarily presents with respiratory distress and absent or diminished breath sounds.
Correct Answer is C
Explanation
A. Instruct the client to report bleeding: While important, assessing for bleeding is not the immediate priority. Minor blood-tinged sputum can be expected, but significant bleeding should be reported. Ensuring airway protection comes first.
B. Inform the client they might experience a low-grade fever: A mild fever may occur within the first 24 hours after bronchoscopy due to irritation, but addressing airway safety and aspiration risk takes precedence.
C. Check the client's gag reflex: The gag reflex must return before offering oral intake to prevent aspiration. The local anesthetic used for the procedure can suppress the reflex, increasing the risk of aspiration if the client drinks or eats too soon.
D. Provide the client with sips of water: Fluids should not be given until the gag reflex has returned. Providing water too soon could result in aspiration, leading to complications such as pneumonia.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
