The nurse is reviewing the client's medical record.

Exhibits

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 has ST segment elevation and elevated cardiac biomarkers, indicating a STEMI. Cardiac catheterization is a priority intervention to identify the blockage and restore perfusion to the heart muscle.
B. Assist with a continuous heparin infusion: Heparin helps prevent further clot formation in clients experiencing an MI. It is part of acute coronary syndrome management, especially when catheterization or PCI is anticipated.
C. Encourage the client to ambulate: Ambulation is not appropriate during the acute phase of an MI, especially with ongoing chest pain, oxygen desaturation, and unstable vitals. Rest is crucial to minimize myocardial oxygen demand.
D. Anticipate an increased dosage of metoprolol: Although beta-blockers are essential post-MI, increasing the dose too early can worsen hypotension and bradycardia. The client’s blood pressure is already low post-nitroglycerin, so a higher dose is not immediately safe.
E. Obtain a prescription for client to be NPO: Clients undergoing cardiac procedures such as catheterization or possible surgery should be NPO to reduce the risk of aspiration and ensure procedural readiness.
F. Request a prescription for an antibiotic: There are no signs of infection such as fever, abnormal WBC count, or pulmonary infiltrates. Antibiotics are unnecessary in the absence of infectious indicators.

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Correct Answer is B

Explanation

A. Attempt to reinsert the protruding viscera: Reinserting eviscerated organs is not within the nurse’s scope of practice and may cause further injury or infection. This should be avoided; the area must be protected and medical help sought immediately.
B. Obtain bottles of warm, sterile 0.9% sodium chloride solution: Sterile saline is used to moisten sterile dressings that cover the protruding organs, preventing tissue drying and contamination while awaiting surgical intervention.
C. Place the client in left lateral recumbent position: The preferred position is supine with knees bent to reduce tension on the abdominal incision; lateral positioning does not prevent further evisceration or reduce discomfort effectively.
D. Apply a firm pressure dressing across the client's abdomen: Applying pressure can damage protruding tissues. Instead, a loose, moist sterile dressing is appropriate to protect the organs without causing harm.

A. Epistaxis B. Xerostomia C. Tinnitus D. Diplopia

Correct Answer is B

Explanation

A. Epistaxis: While radiation can cause mucosal irritation, epistaxis (nosebleeds) is more commonly associated with trauma, anticoagulant use, or nasal cancers, rather than a direct and expected result of radiation therapy to the head and neck.
B. Xerostomia: Radiation to the head and neck often damages salivary glands, leading to xerostomia (dry mouth). This is a common and expected side effect that can affect swallowing, speaking, and increase the risk of oral infections and dental decay.
C. Tinnitus: Tinnitus is associated with ototoxic medications or direct auditory nerve damage, which is less commonly affected by standard radiation fields in head and neck therapy. It is not a typical side effect unless the inner ear is specifically involved.
D. Diplopia: Double vision is usually related to cranial nerve involvement or neurological conditions like stroke or multiple sclerosis. It is not a standard or expected effect of radiation to the head and neck unless adjacent neural structures are compromised.

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The nurse is reviewing the client's medical record. Exhibits 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.

Exhibits

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.