A client is admitted to the telemetry unit due to an episode of substernal chest pain.

Diagnostic tests reveal an elevated ST segment on the electrocardiogram (ECG) and an increased cardiac troponin level.

What would be an appropriate initial nursing intervention?

Reduce anxiety and alleviate pain.

Enhance myocardial oxygenation and decrease cardiac workload.

Remove family stressors and provide a tranquil environment.

Initiate a low-sodium diet and limit fluid intake.

Answer and Explanation

The Correct Answer is B

Choice A rationale
While reducing anxiety and alleviating pain are important, they are not the most appropriate initial nursing intervention for a client with substernal chest pain, elevated ST segment on the ECG, and increased cardiac troponin level.
Choice B rationale
Enhancing myocardial oxygenation and decreasing cardiac workload are crucial initial nursing interventions for a client presenting with these symptoms. These actions can help prevent further damage to the heart muscle.
Choice C rationale
Removing family stressors and providing a tranquil environment, while beneficial, are not the most appropriate initial nursing interventions for a client with these symptoms.
Choice D rationale
Initiating a low-sodium diet and limiting fluid intake are important for managing heart failure, but they are not the most appropriate initial nursing interventions for a client with these symptoms.

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Correct Answer is B

Explanation

Choice A rationale
While fasting may be required before certain procedures, it is not the most crucial piece of information that the nurse needs to relay to the healthcare provider prior to a cardiac catheterization and coronary angiogram.
Choice B rationale
A shellfish allergy is crucial information because the dye used in an angiogram can cause an allergic reaction in people who are allergic to shellfish.
Choice C rationale
Although a previous heart attack is significant medical history, it is not the most crucial piece of information to relay prior to this procedure.
Choice D rationale
The rating of the patient’s pedal pulses is not the most crucial piece of information to relay prior to this procedure.

A. A 59-year-old patient with unstable angina who has just returned from a percutaneous coronary intervention (PCI). B. A 56-year-old patient with variant angina due to receive nifedipine (Procardia). C. A 65-year-old patient who had a myocardial infarction (MI) 4 days ago and is anxious about discharge planned for today. D. A 39-year-old patient with pericarditis complaining of sharp, stabbing chest pain.

Correct Answer is A

Explanation

Choice A rationale
A 59-year-old patient with unstable angina who has just returned from a percutaneous coronary intervention (PCI) should be prioritized for assessment. PCI is a procedure to open blocked or narrowed coronary arteries and can lead to complications such as re-occlusion of the artery or bleeding from the catheter insertion site. Furthermore, unstable angina is a condition that can progress to myocardial infarction if not managed effectively.
Choice B rationale
A 56-year-old patient with variant angina due to receive nifedipine (Procardia) requires monitoring, but is not the highest priority. Variant angina is a form of angina that occurs at rest, often with severe pain, but it is usually well-controlled with medications like nifedipine.
Choice C rationale
A 65-year-old patient who had a myocardial infarction (MI) 4 days ago and is anxious about discharge planned for today is a lower priority for assessment. While it’s important to address the patient’s anxiety and provide education about post-discharge care, this patient is not in immediate danger.
Choice D rationale
A 39-year-old patient with pericarditis complaining of sharp, stabbing chest pain requires assessment, but is not the highest priority. Pericarditis is inflammation of the pericardium, the sac-like covering of the heart, and while it can cause severe pain, it is not typically life- threatening.

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A client is admitted to the telemetry unit due to an episode of substernal chest pain. Diagnostic tests reveal an elevated ST segment on the electrocardiogram (ECG) and an increased cardiac troponin level. What would be an appropriate initial nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When preparing a patient for a cardiac catheterization and coronary angiogram, which piece of information about the patient is crucial for the nurse to relay to the healthcare provider prior to the procedure?

Correct Answer is B

Explanation

After receiving the shift change report about four patients in the cardiac care unit, which patient should the nurse prioritize for assessment?

Correct Answer is A

Explanation

In the context of a patient who has undergone coronary artery bypass grafting using a right radial artery graft, which observation is most crucial for the nurse to report to the healthcare provider?

If a patient diagnosed with hypertension is prescribed Propranolol (Inderal), what patient history should prompt the nurse to consult with the healthcare provider before administering this drug?

The standard policy on the cardiac unit states, “Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg.”. Which patient should the nurse call the health care provider about?

Upon receiving a change-of-shift report about four patients in a heart failure unit, which patient should the nurse prioritize for assessment?

A 56-year-old individual visits his primary care provider for a routine checkup.The physical examination reveals edema, an enlarged liver (hepatomegaly), and muffled heart sounds. Which of the following findings should the nurse be most concerned about?

During a stress test on a treadmill, which observation by the nurse would necessitate immediate action?

The nurse is caring for a client with weak pedal pulses, absent hair on bilateral legs, and a full-thickness wound on the right lateral malleolus with defined margins, including a minimal amount of serous exudate. Which of the following interventions is contraindicated?

What factor would contraindicate the use of propranolol (Inderal) in a 38-year-old obese African American patient with diabetes who is being evaluated for hypertension control?

A client is admitted to the telemetry unit due to an episode of substernal chest pain.

Diagnostic tests reveal an elevated ST segment on the electrocardiogram (ECG) and an increased cardiac troponin level.

What would be an appropriate initial nursing intervention?