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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Apply new gloves when alternating between wound care sites: Using new gloves between wound sites prevents cross-contamination and reduces the risk of infection, which is critical in clients with full-thickness burns due to loss of skin integrity.
B. Provide a diet of fresh fruits and vegetables for the client: While a nutritious diet is important, fresh produce may harbor bacteria and is often restricted in severely immunocompromised burn clients during the acute phase to prevent infection.
C. Clean the equipment in the client's room once per week: Cleaning should be performed daily or more frequently to reduce microbial load and prevent hospital-acquired infections, especially in burn clients who are at high risk.
D. Limit visitation time for the client's children to 40 min per day: There is no strict standard for limiting visitation to this duration; infection control practices and the client's condition guide safe visitation rather than arbitrary time limits.

A. Administer flumazenil IV per facility policy to the client. B. Assess the client's bilateral hand grasp strength. C. Place a padded tongue blade at the client's bedside. D. Check the client's bedside glucose level.

Correct Answer is B

Explanation

A. Administer flumazenil IV per facility policy to the client: Flumazenil is a benzodiazepine reversal agent and is only indicated if the client received a benzodiazepine. Slurred speech in this context is more likely neurologic in origin due to stroke risk.
B. Assess the client's bilateral hand grasp strength: Clients in sickle cell crisis are at increased risk for stroke. New onset slurred speech is a neurological symptom, and assessing for other focal deficits like hand grasp strength helps detect stroke early.
C. Place a padded tongue blade at the client's bedside: This is not appropriate stroke management and is outdated seizure care. There is no indication of seizure activity, and tongue blades should never be inserted in a client’s mouth during a seizure.
D. Check the client's bedside glucose level: While hypoglycemia can cause neurologic symptoms, in a client with sickle cell disease and new slurred speech, stroke must be prioritized due to the high risk of cerebral infarction during crisis.

View Question and Answer

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

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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has full-thickness burns on the lower extremities. Which of the following interventions should the nurse include?

Correct Answer is A

Explanation

A nurse is caring for a client who is experiencing a sickle cell crisis. During morning care, the assistive personnel alerts the nurse that the client is slurring their speech. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

The nurse is reviewing the client's medical record. Exhibits For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?

A nurse is caring for a client who is receiving potassium chloride 40 mEq IV every 4 hr. Which of the following findings indicate the client is becoming hyperkalemic?

A nurse is preparing to administer a blood transfusion to a client. Which of the following actions should the nurse plan to take?

A nurse is caring for a client who has developed a paralytic ileus related to acute pancreatitis and reports pain as 8 on a scale of 0 to 10. The client has prescriptions for multiple PRN pain medications. Which of the following medications should the nurse administer?

A nurse is reviewing a client's cardiac monitor. Which of the following findings should the nurse identify as an indication for synchronized cardioversion?

A nurse is admitting a client who reports chest pain and has been placed on a telemetry monitor. Which of the following should the nurse analyze to determine whether the client is experiencing a myocardial infarction?

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.