HESI 799 RN Exit Exam

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, II, 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- Asses for contraindications for thrombolytic therapy c- Measure ST-segment height and waveform changes. d- Transfer for percutaneous coronary intervention (PCI) - Answer- b. Asses for contraindications for thrombolytic therapy. Rationale: ST segment elevation myocardial infarction (STEMI) usually occurs with complete occlusion of an epicardial coronary artery which requires early reperfusion therapy. Screening the client for fibrinolytic therapy (B) is most important to determine PCI option for rapid reperfusion. If the client is not a candidate for fibrinolytic therapy, then transfer to a PCI unit or facility is indicated. Reperfusion therapy should be delayed in STEMI (A). (C) is of significant concern in ECG interpretation with ST-segment depression, not STEMI An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription? a. 1000, 1600, 2200, 0400 - Answer- 1000, 1600, 2200, 0400 A client is receiving continuous bladder irrigation via a triple-lumen suprapubic catheter that was placed during prostatectomy. Which report by the unlicensed assistive personnel (UAP) requires intervention by the nurse? a. Leakage around catheter insertion site - Answer- Leakage around catheter insertion site A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based on the client's admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply.) A. Headache and tremors. B. Postural hypotension. C. Pallor and diaphoresis. D. Skin hyperpigmentation. E.