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Which of the following actions should the nurse take immediately?
(Select the 4 actions the nurse should take.)

Exhibits

A.

Administer oxygen

B.

Obtain prescription for amiodarone

C.

Place client in semiFowler's position

D.

Monitor blood pressure every 30 minutes

E.

Obtain prescription for a beta blocker

F.

Monitor for neurologic complications

Answer and Explanation

Correct Answer : A,C,E,F

Rationale:

A. Administer oxygen: The client is experiencing labored respirations and increasing distress. Although their oxygen saturation is currently within normal range, supplemental oxygen is a priority to support oxygenation during this acute episode, especially with signs of anxiety and shortness of breath.

B. Obtain prescription for amiodarone: Amiodarone is used for certain ventricular arrhythmias. The client’s heart rhythm is described as regular, though tachycardic, not indicating a need for amiodarone. This is not an immediate priority without evidence of a specific arrhythmia like ventricular tachycardia.

C. Place client in semi-Fowler's position: Elevating the head of the bed helps reduce the work of breathing and improves lung expansion. This position supports respiratory function, especially when the client is experiencing shortness of breath.

D. Monitor blood pressure every 30 minutes: Blood pressure monitoring is important, but this action is not immediate in the face of worsening symptoms. The client needs more urgent interventions first, including respiratory and cardiac stabilization.

E. Obtain prescription for a beta blocker: The client’s heart rate increased significantly to 170/min and they have a history of poorly controlled hypertension. A beta blocker may be needed to reduce sympathetic overactivity and heart rate, helping to lower blood pressure and myocardial oxygen demand.

F. Monitor for neurologic complications: With a blood pressure of 185/100 mmHg and a worsening severe headache, the client is at risk for neurologic complications such as hypertensive encephalopathy or stroke. Close neurologic monitoring is essential to detect early signs of deterioration.


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Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A,B"},"E":{"answers":"B"}}

Explanation

Rationale:

  • Troponin I level: An elevated troponin I level indicates myocardial cell injury and is a key diagnostic marker for MI. Even a value at the upper limit of normal (0.03 ng/mL) warrants concern, especially with accompanying symptoms.
  • ECG result – sinus tachycardia: Sinus tachycardia is nonspecific but may occur in both MI and angina due to pain, anxiety, or sympathetic stimulation. However, more definitive MI-related changes like ST elevation or Q waves would provide clearer diagnostic value.
  • Heart rate: A heart rate of 116/min is elevated and may represent the body’s response to pain, hypoxia, or stress. This can be seen in both angina and MI, though persistent or worsening tachycardia in MI may indicate hemodynamic instability.
  • Heart palpitations: Palpitations are common during episodes of angina and are often due to increased sympathetic tone or transient arrhythmias. They are usually mild and resolve with rest or nitroglycerin in stable angina.
  • Blood pressure: A blood pressure of 158/92 mm Hg indicates hypertension, a known trigger and risk factor for angina. Elevated BP increases myocardial oxygen demand, potentially precipitating chest pain in those with coronary artery disease.

Correct Answer is A

Explanation

Rationale:
A. Stop the heparin infusion for 1 hr: The client’s aPTT is 105 seconds, which is above the protocol threshold of >95 seconds. Per the titration guidelines, the nurse should hold the infusion for 60 minutes and decrease the rate by 3 units/kg/hr after the hold to reduce bleeding risk.

B. Increase the rate of the infusion by 160 units/hr: Increasing the infusion is appropriate only when aPTT is between 30–49 seconds. Since this client's aPTT is elevated, increasing the rate would further prolong clotting time and increase the risk of hemorrhage.

C. Administer heparin 2,400 unit IV bolus: Bolus doses are prescribed only for low aPTT values (30–49 seconds). Giving a bolus when aPTT is elevated can worsen anticoagulation and significantly increase the potential for bleeding complications.

D. Continue the infusion without change: Continuing the infusion is appropriate when aPTT is within the therapeutic range (50–70 seconds). This client’s aPTT is well above that range, indicating excessive anticoagulation that requires adjustment.

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