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 D

Explanation

A. Eat a diet high in carotene:
While a healthy diet is important for overall well-being, there is no evidence to suggest that a diet high in carotene specifically prevents or treats glaucoma. The focus in glaucoma management is on intraocular pressure control.

B. Wear prescription glasses:
Prescription glasses may be beneficial for addressing refractive errors, but they do not specifically address the management of glaucoma. The client's concern about driving through a tunnel is more likely related to changes in peripheral vision associated with glaucoma.

C. Avoid frequent eye pressure measurements:
This is not the most important instruction. Monitoring intraocular pressure is a crucial aspect of glaucoma management, and the frequency of measurements is determined by the healthcare provider. Regular monitoring helps assess the effectiveness of treatment and disease progression.

D. Maintain the prescribed eye drop regimen:
This is the correct answer. The most important instruction for the client is to adhere to the prescribed eye drop regimen. Medications, often in the form of eye drops, are commonly used to lower intraocular pressure and manage glaucoma. Consistent use of prescribed medications is critical for controlling the condition and preventing further vision loss.

A. Administer a topical analgesic. B. Cleanse the mouth with swabs C. Obtain a soft diet for the client. D. Encourage frequent mouth care

Correct Answer is D

Explanation

A. Administer a topical analgesic:
Administering a topical analgesic can help alleviate pain and discomfort associated with oral thrush. However, it addresses the symptom rather than the cause of the issue.

B. Cleanse the mouth with swabs:
Cleansing the mouth with swabs can be part of the care plan for managing oral thrush. It helps remove debris and may reduce the fungal load in the mouth.

C. Obtain a soft diet for the client:
Providing a soft diet is important for clients with oral thrush as it minimizes irritation to the affected area. However, it may not be the first intervention; rather, it is part of the overall care plan.

D. Encourage frequent mouth care:
Encouraging the client to perform frequent mouth care is the most immediate and direct intervention. This includes gentle rinsing with a mild solution, which can help relieve symptoms and prevent the spread of the infection.

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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?

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