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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 male client notifies the nurse that he feels short of breath and has chest pressure radiating down his left arm. A STAT 12-lead electrocardiogram (ECG) is obtained and shows ST segment elevation in leads II, III, aVF, and V4R. The nurse collects blood samples and gives a normal saline bolus. What action is most important for the nurse to implement?
- A. Obtain the results for STAT serum cardiac biomarkers.
- B. Assess for contraindications for thrombolytic therapy.
- C. Measure ST-segment height and waveform changes.
- D. Transfer for percutaneous coronary intervention (PCI).
Correct Answer: B
Rationale: Assessing for contraindications for thrombolytic therapy is crucial as it determines whether the client is a candidate for reperfusion therapy. In this scenario, the client is presenting with symptoms and ECG changes consistent with an acute myocardial infarction (MI). Thrombolytic therapy aims at restoring blood flow to the heart muscle, reducing the size of the infarct. However, it is essential to assess for contraindications such as recent surgery, active bleeding, or a history of stroke to avoid potential complications. Obtaining serum cardiac biomarkers or measuring ST-segment changes are important steps in the diagnosis of MI but are not as time-sensitive as assessing for contraindications to thrombolytic therapy. Transfer for percutaneous coronary intervention (PCI) is a definitive treatment for MI, but assessing for thrombolytic therapy eligibility takes precedence in this acute situation.
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.
The nurse enters a client's room and observes the unlicensed assistive personnel (UAP) making an occupied bed as seen in the picture. What action should the nurse take first?
- A. Place the side rails in an up position.
- B. Assist the UAP in turning the client.
- C. Provide instructions on proper bed-making techniques.
- D. Ask the client if they are comfortable.
Correct Answer: A
Rationale: Correct Answer: The nurse should first place the side rails in an up position. This action is crucial to prevent the client from falling while the bed is being made. Choice B is incorrect as moving or turning the client is not necessary at this point. Choice C is not a priority when immediate safety concerns are present. Choice D, asking the client if they are comfortable, though important, should come after ensuring the client's safety by raising the side rails.
A client with chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which assessment finding is most concerning?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 24 breaths per minute
- C. Use of accessory muscles
- D. Inspiratory crackles
Correct Answer: C
Rationale: The correct answer is C: 'Use of accessory muscles.' In a client with COPD and pneumonia, the use of accessory muscles indicates increased work of breathing. This finding is concerning as it may signal respiratory failure, requiring immediate intervention. Oxygen saturation of 90% (choice A) is low but not as immediately concerning as the increased work of breathing. A respiratory rate of 24 breaths per minute (choice B) is slightly elevated but not as critical as the use of accessory muscles. Inspiratory crackles (choice D) may be present in pneumonia but are not as indicative of impending respiratory failure as the increased work of breathing shown by the use of accessory muscles.
Following routine diagnostic tests, a client who is symptom-free is diagnosed with Paget's disease. Client teaching should be directed toward what important goal for this client?
- A. Maintain adequate cardiac output.
- B. Promote adequate tissue perfusion.
- C. Promote rest and sleep.
- D. Reduce the risk for injury.
Correct Answer: D
Rationale: In Paget's disease, bone remodeling is affected, leading to increased risk for fractures. Therefore, the primary goal of client teaching should focus on reducing the risk for injury. Choices A and B are not directly related to the primary concern of Paget's disease, which is bone fractures. Choice C, promoting rest and sleep, is important for overall health but is not the priority when considering the specific risks associated with Paget's disease.