A nurse at a provider's office receives a telephone call from a client who reports nausea and has unrelieved chest pain after taking a nitroglycerin tablet 5 min ago. Which of the following is an appropriate response by the nurse?
Advise the client to come into the office.
Advise the client to take an antacid.
Instruct the client to call 911.
Tell the client to take another nitroglycerin tablet in 15 min.
The Correct Answer is C
A. Advise the client to come into the office. The client needs immediate emergency intervention, not a routine office visit.
B. Advise the client to take an antacid. Chest pain unrelieved by nitroglycerin may indicate myocardial infarction; an antacid would not help.
C. Instruct the client to call 911. Persistent chest pain unrelieved by nitroglycerin warrants emergency attention due to potential heart attack.
D. Tell the client to take another nitroglycerin tablet in 15 min. The protocol allows taking an additional dose in 5 minutes, but emergency services should be called for unrelieved chest pain.
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Correct Answer is A
Explanation
A. The ST segment is above the isoelectric line. An elevated ST segment is a hallmark sign of acute myocardial infarction (MI), indicating myocardial injury.
B. The QRS intervals are 0.08 second. A QRS interval of 0.08 seconds is within the normal range and does not indicate myocardial infarction.
C. The QT interval is equal to the R to R interval. QT interval measurements are not diagnostic for acute MI.
D. The PR intervals are 0.15 second. A PR interval of 0.15 seconds is within the normal range and is not indicative of acute MI.
Correct Answer is B
Explanation
A. Bounding peripheral pulses: Hypokalemia typically causes weak, thready pulses rather than bounding ones.
B. Decreased deep-tendon reflexes: Hypokalemia can cause muscle weakness and decreased deep-tendon reflexes due to impaired neuromuscular function.
C. Hyperactive bowel sounds: Hypokalemia generally causes decreased or hypoactive bowel sounds due to slowed smooth muscle contraction.
D. Restlessness: Restlessness is not a typical sign of hypokalemia; hypokalemia more commonly causes weakness, lethargy, or fatigue.