A client who underwent cardiac stent placement four days ago arrives to the emergency department reporting a sudden onset of chest pressure and shortness of breath. Which action should the nurse take next?

Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema.

Listen for extra heart sounds, murmurs, and rhythm with the bell of the stethoscope.

Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring.

Verify troponin level assessments are scheduled every 3-6 hours for a series of three

Answer and Explanation

The Correct Answer is C

A. Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema:
This option focuses on assessing perfusion and circulation in the extremities. While it's important in certain situations, in the context of a client who recently underwent cardiac stent placement and is now experiencing chest pressure and shortness of breath, the priority is to assess the cardiac status more directly.

B. Listen for extra heart sounds, murmurs, and rhythm with the bell of the stethoscope:
This option involves auscultating the heart for abnormal sounds or rhythms. While it's a valuable assessment in general, in this particular scenario, obtaining an electrocardiogram (ECG) and initiating continuous cardiac monitoring would provide a more comprehensive and immediate evaluation of the cardiac status.

C. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring:
This is the correct choice. Obtaining a 12-lead ECG and initiating continuous cardiac monitoring is crucial in assessing the client's cardiac function. It allows for the detection of any acute changes in the heart's electrical activity or rhythm, which is essential for timely intervention and management.

D. Verify troponin level assessments are scheduled every 3-6 hours for a series of three:
Monitoring troponin levels is important in assessing cardiac damage, but in this acute situation, obtaining an immediate ECG and initiating continuous cardiac monitoring take precedence for a more real-time evaluation of the client's cardiac status. Troponin levels may be monitored subsequently based on the initial findings.

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Correct Answer is B

Explanation

A. Administer intravenous fluid bolus as prescribed by the healthcare provider.
While hydration is important, the vital signs provided (elevated heart rate and respiratory rate) are more indicative of potential respiratory distress. Administering fluids may be indicated in certain situations, but it may not address the immediate concern of compromised oxygenation.

B. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.
This is the correct choice. The client's elevated heart rate and respiratory rate suggest the need for improved oxygenation. Applying oxygen at a high flow rate via a non-rebreather mask is an immediate intervention to address potential respiratory compromise. Monitoring the pulse oximeter provides real-time feedback on oxygen saturation.

C. Medicate for pain and monitor vital signs according to protocol.
Pain management is an important aspect of post-operative care, but the immediate concern in this scenario is the potential for respiratory distress. Administering pain medication alone may not address the primary issue.

D. Encourage the client to splint the incision with a pillow to cough and deep breathe.
While encouraging the client to cough and deep breathe is important for post-thoracotomy care, the elevated vital signs suggest a need for more immediate intervention to ensure adequate oxygenation. Applying oxygen and monitoring the pulse oximeter take precedence.

A. Return appointments will be needed for IV medication. B. Wearing gloves when handling cold items guards against painful spasms. C. Enrolling in a pain clinic can provide pain relief alternatives D. Painful areas should be rubbed gently until the pain subsides.

Correct Answer is B

Explanation

A. Return appointments will be needed for IV medication:
This statement does not address the specific concern related to pain management in Raynaud's disease, and routine IV medication may not be the primary approach for pain relief in this condition.

B. Wearing gloves when handling cold items guards against painful spasms:
This is the correct answer. Raynaud's disease is characterized by vasospasm of small arteries, often triggered by exposure to cold or stress. Wearing gloves helps to minimize exposure to cold and can prevent painful spasms associated with Raynaud's.

C. Enrolling in a pain clinic can provide pain relief alternatives:
While pain clinics can offer various pain management strategies, the specific recommendation for Raynaud's disease involves minimizing exposure to cold and stress rather than enrolling in a pain clinic.

D. Painful areas should be rubbed gently until the pain subsides:
Rubbing painful areas may not be recommended, as it can potentially aggravate vasospasm in individuals with Raynaud's disease. The emphasis is on preventing triggers like cold exposure.

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A client who underwent cardiac stent placement four days ago arrives to the emergency department reporting a sudden onset of chest pressure and shortness of breath. Which action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instruction should the nurse provide?

Correct Answer is B

Explanation

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