The nurse obtains verbal prescriptions from the healthcare provider for an antianginal, telemetry, and STAT serum analysis for cardiac isoenzymes, after reading back the prescriptions to the healthcare provider of a client's upper gastric burning, left jaw pain, and nausea. Which intervention is most important for the nurse to implement?
Initiate telemetry and assess the client's cardiac rhythm.
Document description of nausea and administer the antiemetic.
Submit electronic prescriptions to the pharmacy and laboratory.
Obtain the client's 10-point score for radiating jaw pain.
The Correct Answer is A
Choice A reason: This is the most important intervention, as the client's symptoms suggest a possible myocardial infarction (MI) or angina. The nurse should initiate telemetry and assess the client's cardiac rhythm for any signs of ischemia, injury, or infarction. The nurse should also administer the antianginal medication as prescribed and monitor the client's response.
Choice B reason: This is a relevant intervention, as nausea is a common symptom of MI or angina, especially in women. The nurse should document the description of nausea and administer the antiemetic medication as prescribed. The nurse should also assess the client's abdominal pain and rule out other causes such as gastritis or ulcer.
Choice C reason: This is a necessary intervention, as the verbal prescriptions need to be submitted electronically to the pharmacy and laboratory for processing and verification. The nurse should also document the verbal prescriptions and the read-back process in the client's record. However, this is not the most important intervention, as it can be done after the client's condition is stabilized.
Choice D reason: This is not a priority intervention, as the client's jaw pain is likely related to the cardiac problem and not to a separate issue. The client's pain should be assessed using a standard scale such as the numeric rating scale or the Wong-Baker FACES scale. The nurse should also administer analgesics as prescribed and monitor the client's pain level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Letting each family member ask a question one at a time may be overwhelming and time-consuming for the nurse. It may also increase the anxiety and confusion of the family members.
Choice B reason: Requesting the healthcare provider to speak with the family may be helpful, but it is not the first intervention. The nurse should first assess the family's needs and concerns, and provide clear and consistent information.
Choice C reason: Paging a chaplain on call to be present for questions may be appropriate for some families, but it is not a priority intervention. The nurse should first determine the family's spiritual and emotional needs, and respect their preferences.
Choice D reason: Asking the family to identify a specific spokesperson is the best intervention. It helps to reduce the number of questions and conflicting information, and to facilitate effective communication between the nurse and the family.
Correct Answer is C
Explanation
The correct answer is c. The client who has pneumonia following a total knee replacement, and is receiving clarithromycin orally.
Choice A reason: This client has a complex wound care and an intravenous antibiotic therapy, which require the skills and knowledge of a registered nurse. Therefore, this client should not be assigned to a PN.
Choice B reason: This client has a chronic condition that does not require frequent assessment or intervention. Therefore, this client can be assigned to a UAP under the supervision of a nurse.
Choice C reason: This client has a stable condition that can be managed with oral medication and routine monitoring. Therefore, this client can be assigned to a PN who can administer oral drugs and report any changes to the nurse.
Choice D reason: This client has a high risk of aspiration and complications due to the enteral feeding and the neurological impairment. Therefore, this client should not be assigned to a PN.
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