A 65-year-old woman with no history of pulmonary or cardiovascular issues presents to the emergency department with nausea, fatigue, and fullness and pain of the abdomen. The nurse knows the assessment tests that will be ordered first will include:
Abdominal ultrasound and chest X-ray.
Test of the acidity of the gastric contents and assessment of the throat.
Electrocardiogram (EKG) and serum troponin levels.
Abdominal X-ray and colonoscopy.
The Correct Answer is C
Choice A reason:
Abdominal ultrasound and chest X-ray are not the first-line tests for a patient presenting with these symptoms. While they can be useful in assessing certain conditions, the priority in this case is to rule out cardiac causes, especially given the symptoms that could indicate a cardiac event.
Choice B reason:
Testing the acidity of gastric contents and assessing the throat is not relevant for the initial evaluation of these symptoms. While gastrointestinal issues can present with similar symptoms, the first step should be to rule out more serious cardiac causes.
Choice C reason:
Electrocardiogram (EKG) and serum troponin levels are the correct answer. These tests are critical in assessing cardiac function and identifying potential myocardial infarction or other cardiac issues. Given the patient's symptoms, which can be indicative of a cardiac event, these tests are prioritized to rule out any immediate cardiac threats.
Choice D reason:
Abdominal X-ray and colonoscopy are not appropriate first-line tests in this scenario. While they may be necessary later to investigate gastrointestinal issues, the primary concern given the patient's symptoms is to rule out cardiac events with an EKG and serum troponin levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
As mentioned earlier, infusion reactions are common with Amphotericin B, including symptoms like fever and chills. Therefore, recognizing that these reactions occur is correct and indicates a proper understanding of the medication's effects.
Choice B reason:
Rapid administration of Amphotericin B is incorrect because it increases the risk of severe side effects. The infusion should be slow to ensure patient safety, indicating that the student needs further teaching on this point. Thus, this choice is incorrect and suggests a misunderstanding.
Choice C reason:
Frequent rotation of the IV site or the use of a central line is standard practice to minimize the risk of phlebitis. This practice is correct and shows that the student understands how to manage the complications associated with Amphotericin B infusion.
Choice D reason:
Amphotericin B's primary use is to treat systemic fungal infections. This is a correct statement, reflecting an accurate understanding of the drug's purpose and does not require further teaching.
Correct Answer is A
Explanation
Choice A reason:
Vitamin K (phytonadione) is the antidote for warfarin overdose. It works by promoting the synthesis of clotting factors that are inhibited by warfarin, thereby reversing the anticoagulant effects. In cases of excessive warfarin intake, administering vitamin K helps restore normal clotting function.
Choice B reason:
Protamine sulfate is the antidote for heparin overdose, not warfarin. It works by neutralizing the anticoagulant effects of heparin, but it has no effect on warfarin-induced anticoagulation. Therefore, it is not appropriate for this situation.
Choice C reason:
A PTT lab test measures the effectiveness of the intrinsic pathway of coagulation and is primarily used to monitor heparin therapy. It is not relevant for managing warfarin overdose, as warfarin affects the extrinsic pathway, which is measured by the PT/INR test.
Choice D reason:
While an INR lab test is essential for monitoring the therapeutic levels of warfarin, the immediate need in this situation is to reverse the effects of the overdose. Administering vitamin K is the necessary intervention to counteract the excessive anticoagulation caused by warfarin.
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