A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?
Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema.
Secure client consent for coronary angiography and percutaneous coronary intervention.
Administer four 81 mg aspirin tablets providing instructions to chew before swallowing.
Place an indwelling urinary catheter and institute strict intake and output measurements.
The Correct Answer is C
Given the client's symptoms of constant chest pressure that is unrelieved with rest, along with the client's appearance of anxiety, pallor, and diaphoresis, it indicates a high likelihood of an acute coronary event, such as a myocardial infarction (heart attack). In this situation, the nurse should prioritize immediate actions that address the potential cardiac emergency.
Aspirin is an essential medication in the initial management of acute coronary syndrome, including unstable angina and myocardial infarction. It helps to inhibit platelet aggregation and reduce the risk of clot formation in the coronary arteries. The chewable form of aspirin is recommended because it allows for more rapid absorption.
While evaluating extremities for perfusion, pulse volume, and pitting edema is important in assessing the client's overall cardiovascular status, it is not the immediate next step when faced with a suspected acute coronary event.
Securing client consent for coronary angiography and percutaneous coronary intervention (PCI) is a relevant step in the management of unstable angina and myocardial infarction, but it is not the immediate action to be taken in the emergency department. The client requires stabilization and initial medical interventions before procedural consent can be obtained.
Placing an indwelling urinary catheter and instituting strict intake and output measurements is not a priority action in this situation. The focus should be on addressing the potential acute coronary event and ensuring the client's cardiac stability. Urinary catheterization and monitoring of intake and output can be considered later, if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect - Developing and implementing new screening protocols does not directly indicate the effectiveness of a primary prevention program. It might indicate improved detection, but not necessarily prevention.
B) Incorrect - This outcome relates to secondary prevention (rehabilitation after disease complications) rather than primary prevention.
C) Correct- An improvement in average client scores on risk factor knowledge tests suggests that the primary prevention program has successfully educated clients about behaviors and practices that can help prevent sexually transmitted diseases. This improvement indicates that clients have a better understanding of the risks and protective measures, which is a key indicator of program effectiveness.
D) Incorrect - Diagnosing clients early in their disease process is an outcome of early detection (secondary prevention), not primary prevention.
Correct Answer is A
Explanation
A low serum creatinine level indicates decreased muscle mass or impaired kidney function. However, it does not necessarily indicate that the 24-hour creatinine clearance test should be withheld or delayed.
Initiating the urine collection as prescribed allows for the accurate assessment of creatinine clearance and provides valuable information about the client's kidney function. The test results can help guide further evaluation and management of the client's condition.
Assessing the client's serum BUN level, notifying the healthcare provider of the results, or assessing for signs of hypokalemia may be relevant in certain situations but are not the immediate priority based on the information provided.
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