Be delayed in stemi a c is of significant concern in

be delayed in STEMI (A). (C) is of significant concern in ECG
interpretation with ST-segment depression, not STEMI
733- 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- Irregular heart rate
c- Skin hyperpigmentation
d- Postural hypotension
e- Pallor and diaphoresis
734- A client with rapid respirations and audible rhonchi is
admitted to the intensive care unit because of a pulmonary
embolism (PE). Low-flow oxygen by nasal cannula and weight
based heparin protocol is initiated. Which intervention is most
important for the nurse to include in this client s ‟ plan of
care?
a- Monitor deep vein blood flow using Doppler
b- Evaluate daily blood clotting factors.
c- Apply antiembolism stockings.

d- Maintain strict bed rest.
Rationale: Monitoring clotting factors is the most important intervention
to include in this client s plan of care following oxygen administration, ‟
IV fluids and heparin administration to prevent clot enlargement. Ac and
D should be included in the client s plan of care, but these interventions ‟
do not have the priority of B
735- The nurse enters a client s ‟ room to administer scheduled
daily medications and observes the client leaning forward and
using pursed lip breathing. Which action is most important for
the nurse to implement first?
a- Administer schedule medications
b- Offer the client PRN anxiolytic
c- Assess the lungs for wheezing
d- Evaluate the oxygen saturation.
Rationale: The client is exhibiting symptoms of an acute exacerbation of
a chronic obstructive lung disease such as emphysema. The client…
baseline oxygen level should be compared to the current level to
determine if respiratory decompensation is occurring. Schedule
medications can be administered after completing the oxygen saturation
assessment. Respiratory distress often makes a client anxious, which
may worsen the symptoms, so should be considered after implementing
D. Assessing the lung for wheezing does not reveal further respiratory

compromise
736- During a clinic visit, a client with a kidney transplant ask,
“What will happen if chronic rejection develops?” which
response is best for the nurse to provide?
a- The immunosuppressant medication will be increased until
the rejection subside
b- Dialysis may be necessary until the chronic rejection can be
reversed.
c- Dialysis would need to be resumed if chronic rejection
becomes a reality
d- A different combination of immunosuppressant medications
will be implemented.
Rationale: Chronic rejection is managed conservatively by treating the
symptoms until dialysis is needed. Immunosuppressant medication
dosage are not increased when chronic rejection occurs, but are during
acute rejection.