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. Initiate cardiac telemetry:
Cardiac telemetry is not the immediate priority in this case. Kidney stones are more likely to cause severe localized pain rather than cardiac-related symptoms.

B. Administer a PRN dose of a laxative:
Laxatives are not indicated for the management of kidney stones or the associated flank pain. The priority is to address the specific needs related to the possible passage of kidney stones.

C. Implement seizure precautions:
Seizure precautions are not relevant to the sudden onset of severe flank pain in the context of hyperparathyroidism. The focus should be on managing pain, assessing for kidney stone passage, and addressing the underlying cause.

D. Begin straining all urine.
Straining all urine allows for the collection and examination of any passed stones. This information is important for identifying the composition of the stones and guiding further management.

A. Hypovolemia and electrocardiographic (ECG) changes. B. Uremic irritation of mucous membranes and skin surfaces. C. Side effects of total parental nutrition (TPN) and Intralipids. D. Elevated creatinine and blood urea nitrogen (BUN)

Correct Answer is A

Explanation

A. Hypovolemia and electrocardiographic (ECG) changes:
During the diuretic phase of AKI, there is an increased urine output, and the risk of dehydration and hypovolemia is elevated. The nurse should closely monitor fluid balance to prevent dehydration, and ECG changes may occur due to electrolyte imbalances (such as hypokalemia) associated with diuresis.

B. Uremic irritation of mucous membranes and skin surfaces:
Uremic symptoms are more prominent in the oliguric phase of AKI when waste products accumulate in the blood. In the diuretic phase, the focus shifts more toward managing fluid and electrolyte balance.

C. Side effects of total parental nutrition (TPN) and Intralipids:
TPN and Intralipids are not directly related to the diuretic phase of AKI. Monitoring for side effects of TPN and Intralipids may be relevant in other clinical contexts but is not the primary concern in the diuretic phase.

D. Elevated creatinine and blood urea nitrogen (BUN):
Monitoring creatinine and BUN levels is important for assessing kidney function, but in the diuretic phase, the focus shifts to managing fluid and electrolyte balance. The risk of hypovolemia and electrolyte imbalances is more immediate during this phase.

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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

A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care?

Correct Answer is D

Explanation

A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI Which parameters are most important for the nurse to plan to carefully monitor?

Correct Answer is A

Explanation

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