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
A. Anticipate client to be prepped for cardiac catheterization: The client presents with symptoms and diagnostic results indicative of an acute myocardial infarction (MI), such as chest pain, elevated troponin levels, and ST segment elevation on the ECG. Cardiac catheterization is a standard procedure to assess the extent of coronary artery blockage and possibly perform an intervention such as angioplasty or stent placement.
B. Assist with a continuous heparin infusion: Heparin is commonly used in the management of acute coronary syndromes, including MI, to prevent further clot formation. Given the client's elevated cardiac markers and ECG changes, initiating heparin therapy is appropriate.
C. Encourage the client to ambulate: This is not appropriate in the acute phase of an MI. The client should be kept on bed rest to decrease the workload on the heart and prevent further complications.
D. Anticipate an increased dosage of metoprolol: The provider has already prescribed a specific metoprolol regimen. Increasing the dosage further without specific clinical indication and provider order is not appropriate at this time.
E. Obtain a prescription for client to be NPO: If the client is potentially going for a cardiac catheterization or any other urgent cardiac procedure, it is essential to keep the client NPO to reduce the risk of aspiration during the procedure.
F. Request a prescription for an antibiotic: There is no indication of an infection that would require antibiotics based on the provided information. The client's symptoms and diagnostic results are consistent with an acute coronary event, not an infectious process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
The symptoms of chest tightness radiating to the left arm, along with nausea, diaphoresis, shortness of breath, and an irregular, tachycardic heart rate are classic signs of a myocardial infarction. The faint pulses in myocardial infarction, can be caused by a reduced blood flow to the heart muscle due to a blockage of a coronary artery. The reduced blood flow result in a cool skin.
Correct Answer is A
Explanation
A. Protamine sulfate is the antidote for heparin and is necessary in case of heparin-induced bleeding or overdose.
B. Vitamin K is the antidote for warfarin, not heparin.
C. Flumazenil is the antidote for benzodiazepines, not heparin.
D. Acetylcysteine is used for acetaminophen overdose, not heparin.
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