The nurse is providing care for a client admitted to the hospital with reports of chest pain. After receiving a total of three nitroglycerin sublingual tablets, the client states, "The pain has not got-ten any better"
What does the nurse do next? a. Place the client in a semi-Fowler's posi-tion.
b. Administer intravenous nitroglycerin.
c. Begin supplemental oxygen at 2 L/min.
d. Notify the health care provider.
D
When a client experiences chest discomfort unrelieved by nitroglycerin, the client may be expe-riencing a myocardial infarction. The provider should be notified and the client prepared for transfer to a unit prepared to provide specialized cardiac care.
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The nurse is performing a breast examination. Which of these statements best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination? Have the woman:
a. Bend over and touch her toes. b. Lie down on her left side and notice any retraction. c. Shift from a supine position to a standing position, and note any lag or retraction. d. Slowly lift her arms above her head, and note any retraction or lag in movement.
A 13-year-old African American boy comes to the ER complaining of fatigue and a rapid heartbeat. In conversation with the father, it becomes apparent to you that the boy has grown 2 inches in the previous 5 months
What is the first problem the health care team would attempt to rule out? A) Sickle cell anemia B) Iron deficiency anemia C) Thalassemia D) Aplastic anemia
The nurse is assessing a patient's bladder by percussion. The nurse elicits dullness after voiding. What does this finding indicate?
A) Incomplete bladder emptying B) Kidney enlargement C) Ureteral obstruction D) Dehydration
The nurse has just completed the assessment of a client admitted with a gunshot wound to the femoral artery. Which of the following would be considered the priority nursing diagnosis for this client?
1. Ineffective Airway Clearance 2. Excess Fluid Volume 3. Decreased Cardiac Output 4. Ineffective Coping