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.

Answer and Explanation

Correct Answer : A,B,E

A. Anticipate client to be prepped for cardiac catheterization: The client’s presentation, including chest pain, ST-segment elevation, elevated troponins, and unstable vital signs, indicates an acute myocardial infarction. Cardiac catheterization is the definitive diagnostic and interventional procedure to restore coronary perfusion.

B. Assist with a continuous heparin infusion: Anticoagulation is a critical component of STEMI management. Heparin is typically started immediately (along with antiplatelet medications like Aspirin, which is already prescribed) to prevent the existing clot from propagating and to prevent the formation of new clots in the coronary arteries.

C. Encourage the client to ambulate: Ambulation is contraindicated in acute myocardial infarction with ongoing chest pain and unstable hemodynamics. Early activity could increase myocardial oxygen demand and worsen ischemia, so the client should remain on bed rest until stabilized and cleared for activity.

D. Anticipate an increased dosage of metoprolol: The client's blood pressure (110/62 mmHg at 12:00) has dropped significantly since the initial presentation and is now borderline low, and the heart rate is still high. Increasing the dosage of a beta-blocker (metoprolol) at this time could cause a dangerous drop in blood pressure and worsen shock.

E. Obtain a prescription for client to be NPO: The client may require urgent procedures such as cardiac catheterization or surgery. Keeping the client NPO prevents aspiration and ensures readiness for potential interventions.

F. Request a prescription for an antibiotic: There is no indication of infection in the client’s presentation or diagnostic results. Administering antibiotics would not address the acute cardiac event and is unnecessary unless new signs of infection develop.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. "You can cross your legs at the ankles when sitting down.": Crossing legs, even at the ankles, can increase the risk of hip dislocation following total hip arthroplasty. Clients should avoid crossing legs to maintain proper joint alignment and prevent complications.

B. "Clean the incision daily with hydrogen peroxide.": Hydrogen peroxide can damage healing tissue and delay wound healing. The incision should be cleaned gently with mild soap and water or as instructed by the surgeon to prevent infection without harming tissue.

C. "You should use an incentive spirometer every 8 hours.": Incentive spirometry is typically recommended more frequently, usually 10 times per hour while awake, to prevent postoperative pulmonary complications. Every 8 hours would be insufficient for effective lung expansion.

D. "Install a raised toilet seat in your bathroom.": A raised toilet seat helps the client maintain hip precautions by reducing hip flexion beyond 90 degrees, decreasing the risk of dislocation. This is an important safety modification for home care following hip arthroplasty.

A. Weight gain B. Bradycardia C. Hypotension D. Loss of skin turgor

Correct Answer is A

Explanation

A. Weight gain: Weight gain is an expected finding in hypervolemia because excess fluid accumulates in the body, increasing overall body weight. Daily weight monitoring is a key indicator for assessing fluid status in clients at risk for volume overload.

B. Bradycardia: Hypervolemia often increases cardiac workload, which can lead to tachycardia rather than bradycardia. A slow heart rate is not typically associated with fluid overload.

C. Hypotension: Hypervolemia generally causes increased blood pressure due to the expanded intravascular volume. Hypotension is more commonly associated with hypovolemia or fluid loss.

D. Loss of skin turgor: Loss of skin turgor is a sign of dehydration or fluid deficit, not hypervolemia. Clients with fluid overload may have edema, but their skin turgor is usually normal or may appear taut rather than decreased.

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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.

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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.