A client enters the ER complaining of severe chest pain. A myocardial infarction is suspected. A 12 lead ECG appears normal, but the doctor admits the client for further testing until cardiac enzyme studies are returned. All of the following will be included in the nursing care plan. Which activity has the highest priority?
a. Monitoring vital signs
b. Completing a physical assessment
c. Maintaining cardiac monitoring
d. Maintaining at least one IV access site
Ans: c. Maintaining cardiac monitoring
Even though initial tests seem to be within normal range, it takes at least 3 hours for the cardiac enzyme studies to register. In the meantime, the client needs to be watched for bradycardia, heart block, ventricular irritability, and other arrhythmias. Other activities can be accomplished around the MI monitoring.
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A nurse assesses a client who is experiencing an acid-base imbalance. The client's arterial blood gas values are pH 7.32, PaO2 94 mm Hg, PaCO2 34 mm Hg, and HCO3- 18 mEq/L. For which clinical manifestations should the nurse assess? (Select all that apply
a. Reduced deep tendon reflexes b. Drowsiness c. Increased respiratory rate d. Decreased urinary output e. Positive Trousseau's sign
The nurse administers an anticholinergic medication to the patient. When assessing this patient, what finding will the nurse consider a secondary effect of the drug?
A) Nasal congestion B) Tachycardia C) Hyperthermia D) Profuse sweating
A client is complaining of pain in the lower-left quadrant of the abdomen. The nurse prepares to percuss the abdomen and notes that the client has a great deal of hair on the lower abdomen
Which action by the nurse is appropriate prior to percussing the client's abdomen? A) Moistening the abdominal hair B) Documenting that the client has hirsutism C) Cutting the client's hair over the entire abdomen D) Discontinuing the use of percussion, palpate the abdomen only.
Which of the following recommendations are appropriate initiatives for colleges to invest in to help nurses become politically active and effective?
a. Assign students to report on state and national legislation affecting nurses. b. Highly encourage nursing students to minor in political science. c. Insist that nursing students join the American Nurses Association in order to graduate. d. Require course work in sociology and economics.