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 C
Explanation
A. Genital herpes: Herpes simplex virus (HSV) is a common sexually transmitted infection, but it is not a nationally notifiable disease. Reporting is not mandatory in most jurisdictions, although counseling and partner notification are recommended.
B. Varicella zoster: Chickenpox (primary varicella infection) is reportable in some states, but herpes zoster (shingles) is generally not required to be reported. However, outbreaks in certain settings, such as schools or healthcare facilities, may need notification.
C. Tuberculosis: Tuberculosis is a highly contagious airborne disease that requires mandatory reporting to public health authorities. Reporting ensures contact tracing, outbreak control, and public health interventions to prevent further transmission.
D. Clostridium difficile: While Clostridium difficile infections are of significant concern in healthcare settings, they are not universally reportable to the local health department. Infection control measures are implemented within facilities, but routine reporting is not always required.
Correct Answer is B
Explanation
A. "The surgeon will make a small incision in your abdomen.": A hysterosalpingography is a fluoroscopic imaging procedure that does not require surgical incisions. Contrast dye is injected through the cervix to visualize the uterus and fallopian tubes.
B. "You may experience referred shoulder pain.": Referred shoulder pain is a common side effect due to peritoneal irritation caused by the contrast dye if it spills into the peritoneal cavity, particularly when the fallopian tubes are patent. This discomfort is temporary and resolves on its own.
C. "Your procedure will be scheduled during menstruation.": The test is typically scheduled after menstruation but before ovulation (days 7-10 of the cycle) to ensure the uterus is clear of blood and to avoid disrupting an early pregnancy.
D. "Warm saline will be instilled via the cervix.": Hysterosalpingography uses iodine-based contrast dye for X-ray imaging, not warm saline. Saline infusion is used in sonohysterography, which is an ultrasound-based procedure.
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