Nokea
A client has chest pain rated at 8 on a 10 point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and Troponin levels are elevated. What is the highest priority for nursing management of this client at this time?
- A. Monitor daily weights and urine output.
- B. Permit unrestricted visitation by family and friends.
- C. Provide client education on medications and diet.
- D. Reduce pain and myocardial oxygen demand.
Correct Answer: D
Rationale: The client is experiencing an acute myocardial infarction, indicated by ST elevation and elevated troponin. Reducing pain and myocardial oxygen demand is critical to minimize further cardiac damage.
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The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 5 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.
Click to highlight the orders that the nurse should consider a priority.
- A. Perform admission medication reconciliation and admit the client to the intensive care unit
- B. Remove the client's clothing
- C. Start a large-bore peripheral vascular access device
- D. 0.9% sodium chloride (normal saline) 1000 mL, IV, once
- E. Obtain medical records from the client's outpatient primary healthcare provider
- F. Insert temperature-sensing indwelling urinary catheter
- G. Apply a cooling blanket to the client
Correct Answer: B,C,D,F,G
Rationale: Priority orders address immediate life-threatening issues: removing clothing (B), IV access (C), saline (D), temperature catheter (F), and cooling blanket (G) manage heat stroke and hypotension. Medication reconciliation (A) and medical records (E) are secondary.
Interferon alfa-2b (Intron A) has been prescribed to treat a client with chronic hepatitis B. The nurse should assess the client for which of the following adverse effects?
- A. Retinopathy.
- B. Constipation.
- C. Flulike symptoms.
- D. Hypoglycemia.
Correct Answer: C
Rationale: Interferon alfa-2b commonly causes flulike symptoms (C), such as fever, chills, and fatigue, which are expected adverse effects. Retinopathy (A), constipation (B), and hypoglycemia (D) are not typically associated with this medication.
The nurse has asked the nursing assistant to ambulate a client with Parkinson's disease. The nurse observes the nursing assistant pulling on the client's arms to get the client to walk forward. The nurse should:
- A. Have the nursing assistant keep a steady pull on the client to promote forward ambulation.
- B. Explain how to overcome a freezing gait by telling the client to march in place.
- C. Assist the nursing assistant with getting the client back in bed.
- D. Give the client a muscle relaxant.
Correct Answer: B
Rationale: Teaching the client to march in place helps overcome freezing gait, a common Parkinson's symptom. Pulling on arms is unsafe, returning to bed is unnecessary, and muscle relaxants are inappropriate.
The nurse is caring for a client in the emergency department who has overdosed on morphine. Which medication does the nurse anticipate to be ordered to reverse the effects of morphine?
- A. sodium bicarbonate
- B. flumazenil
- C. diphenhydramine
- D. naloxone
Correct Answer: D
Rationale: Naloxone is an opioid antagonist used to reverse morphine overdose effects, such as respiratory depression.
A client is receiving dopamine hydrochloride for treatment of shock. The nurse should:
- A. Administer pain medication concurrently.
- B. Monitor blood pressure continuously.
- C. Evaluate arterial blood gases at least every 2 hours.
- D. Monitor for signs of infection.
Correct Answer: B
Rationale: Dopamine can cause significant changes in blood pressure due to its inotropic and vasopressor effects. Continuous blood pressure monitoring is essential to titrate the dose and prevent complications. Pain medication, arterial blood gases, and infection monitoring are not primary.