A client admitted to the coronary care unit with a myocardial infarction begins to develop increased pulmonary congestion, an increase in heart rate from 80 to 102 beats/min, and cold, clammy skin. What is the nurse's best first action?
A. Notify the physician.
B. Increase the IV flow rate.
C. Place the client in supine position.
D. Prepare the client for emergency echocardiography.
A
The nurse recognizes these manifestations as impending cardiogenic shock. The physician or health care provider is notified immediately so that efforts can be made to reverse this condition, because it carries a mortality rate of 65% to 100%.
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The nurse is evaluating the adequacy of the burn-injured client's nutritional intake. Which laboratory value is the best indicator of nutritional status?
A) Creatine phosphokinase (CPK) B) BUN levels C) Hemoglobin D) Albumin level
Which of the following acts of legislation provides funding that guarantees free and appropriate education in the least restrictive environment without bias and discrimination?
a. Americans with Disabilities Act b. Individuals with Disabilities Education Act c. Section 504 of the Rehabilitation Act d. Special Education Act
A nurse is obtaining the history of a patient who reveals that he had an MI 5 years ago. When the admission 12-lead ECG is reviewed, Q waves are noted in leads V3 and V4 only. Which of the following conclusions is most consistent with this situation?
a. The patient may have had a posterior wall MI. b. The patient must have had a right ventricular MI. c. The admission 12-lead ECG was done incorrectly. d. The patient may have had an anterior MI.
As relates to fetal positioning during labor, nurses should be aware that:
a. Position is a measure of the degree of descent of the presenting part of the fetus through the birth canal. b. Birth is imminent when the presenting part is at +4 to +5 cm below the spine. c. The largest transverse diameter of the presenting part is the suboccipitobregmatic diameter. d. Engagement is the term used to describe the beginning of labor.