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A client with a history of myocardial infarction is experiencing chest pain. Which intervention should the nurse implement first?
- A. Administer oxygen therapy as prescribed.
- B. Administer aspirin as prescribed.
- C. Administer nitroglycerin sublingually as prescribed.
- D. Obtain an electrocardiogram (ECG).
Correct Answer: A
Rationale: Administering oxygen therapy is the initial priority in managing chest pain in a client with a history of myocardial infarction. Oxygen therapy helps improve oxygenation, which is crucial in reducing myocardial damage. While administering aspirin and nitroglycerin are essential interventions in the treatment of myocardial infarction, oxygen therapy takes precedence because it addresses the immediate need for oxygen supply to the heart muscle. Obtaining an ECG is important but can be done after ensuring adequate oxygenation.
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A client who is post-op day 1 after abdominal surgery reports pain at the incision site. The nurse notes the presence of a small amount of serosanguineous drainage. What is the most appropriate nursing action?
- A. Apply a sterile dressing to the incision.
- B. Reinforce the dressing and document the findings.
- C. Remove the dressing and assess the incision site.
- D. Notify the healthcare provider.
Correct Answer: B
Rationale: The correct answer is to reinforce the dressing and document the findings. It is important to monitor the incision site closely after surgery, especially when there is a small amount of serosanguineous drainage. Reinforcing the dressing helps maintain cleanliness and pressure on the wound. Documenting the findings is crucial for tracking the client's progress and alerting healthcare providers if necessary. Applying a sterile dressing (Choice A) may not be needed if the current dressing is intact. Removing the dressing (Choice C) can increase the risk of contamination. Notifying the healthcare provider (Choice D) is not the first step for minor drainage on post-op day 1.
A client with chronic kidney disease (CKD) is scheduled for a renal biopsy. Which laboratory value is most concerning?
- A. Serum potassium of 5.5 mEq/L
- B. Serum creatinine of 1.5 mg/dl
- C. Serum creatinine of 2.5 mg/dl
- D. White blood cell count of 8,000/mm3
Correct Answer: C
Rationale: A serum creatinine level of 2.5 mg/dl is the most concerning laboratory value in a client with chronic kidney disease scheduled for a renal biopsy. An elevated serum creatinine level indicates impaired kidney function, which is critical information before performing a renal biopsy. Option A (Serum potassium of 5.5 mEq/L) may be concerning for hyperkalemia but is not directly related to the renal biopsy procedure. Option B (Serum creatinine of 1.5 mg/dl) is within normal limits, suggesting relatively normal kidney function. Option D (White blood cell count of 8,000/mm3) is within the normal range and not directly related to the renal biopsy procedure or CKD management.
A client with a history of chronic heart failure is admitted with shortness of breath and crackles in the lungs. Which intervention should the nurse implement first?
- A. Administer oxygen therapy as prescribed.
- B. Administer a loop diuretic as prescribed.
- C. Administer intravenous morphine as prescribed.
- D. Obtain an arterial blood gas (ABG) sample.
Correct Answer: A
Rationale: Administering oxygen therapy is the priority intervention for a client with chronic heart failure presenting with shortness of breath and crackles in the lungs. Oxygen therapy helps improve oxygenation, which is crucial in managing respiratory distress. Loop diuretics (Choice B) may be indicated to manage fluid overload in heart failure but are not the immediate priority in this case. Administering morphine (Choice C) is not the first-line intervention for shortness of breath in heart failure and should be considered after addressing oxygenation and underlying causes. Obtaining an arterial blood gas sample (Choice D) can provide valuable information but is not the initial action needed to address the client's acute respiratory distress.
An adult male who lives alone is brought to the Emergency Department by his daughter who found him unresponsive. Initial assessment indicated that the client has minimal respiratory effort, and his pupils are fixed and dilated. At the daughter's request, the client is intubated and ventilated. Which nursing intervention has the highest priority?
- A. Notify the client's minister of his condition.
- B. Determine if the client has an executed living will.
- C. Provide the family with information about palliative care.
- D. Discuss the possibility of organ donation with the family.
Correct Answer: B
Rationale: Verifying whether the client has an executed living will is crucial to ensuring that his treatment preferences are followed. In this critical situation, knowing the client's wishes regarding medical interventions is paramount. Options A, C, and D are not the highest priority as they do not directly address the immediate need to determine the client's treatment preferences.
A client is receiving a full-strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement?
- A. Add equal amounts of water and feeding to a feeding bag and infuse at 50 ml/hour
- B. Continue the full-strength feeding after decreasing the rate of infusion to 25 ml/hour
- C. Maintain the present feeding until diarrhea subsides and then begin the new prescription
- D. Withhold any further feeding until clarifying the prescription with the healthcare provider
Correct Answer: A
Rationale: The correct intervention is to dilute the formula by adding equal amounts of water and feeding to a feeding bag and infusing it at 50 ml/hour. This can help alleviate the diarrhea that has developed. Diarrhea can occur as a complication of enteral tube feeding and can be due to a variety of causes, including hyperosmolar formula. Choice B is incorrect as continuing the full-strength feeding, even at a lower rate, may not address the issue of diarrhea. Choice C is incorrect because it is important to follow the new prescription to manage the diarrhea effectively. Choice D is incorrect as withholding feeding without taking appropriate action may delay necessary intervention.