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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

less than body requirements would be the nursing problem with the highest priority for an adolescent with anorexia nervosa. Anorexia nervosa is characterized by a severe restriction of food intake leading to a significantly low body weight, which can have serious physical and psychological consequences. Therefore, addressing the client's malnutrition and promoting adequate nutrition intake is crucial to prevent further complications.

Disturbed Body Image, Interrupted Family Processes, and Noncompliance with treatment regimen are important nursing problems to address, but they are secondary to the client's malnutrition.

A. Determine how the client is administering the medication. B. Advise the client to gargle with warm salt water twice daily. C. Report the client's jaw pain to the healthcare provider. D. Confirm that this is a common symptom of osteoporosis.

Correct Answer is C

Explanation

Jaw pain in a client taking alendronate, a bisphosphonate, for postmenopausal osteoporosis may be a sign of a rare but serious side effect called osteonecrosis of the jaw (ONJ). Therefore, the nurse should respond by: Report the client's jaw pain to the healthcare provider.

Jaw pain can be an indication of ONJ, a condition characterized by the death of jawbone tissue. It is important to notify the healthcare provider so that further evaluation and appropriate management can be initiated. The healthcare provider will determine the best course of action, which may include referral to a specialist for further assessment and treatment.

Determining how the client is administering the medication is not the immediate concern in this situation. While it is important to ensure that the client is following proper administration instructions for alendronate, addressing the jaw pain takes precedence.

Advising the client to gargle with warm salt water twice daily may not be sufficient or appropriate for managing jaw pain related to alendronate use. The client needs a comprehensive assessment by the healthcare provider to determine the cause of the jaw pain and provide appropriate interventions.

Confirming that jaw pain is a common symptom of osteoporosis is not accurate. While osteoporosis can lead to bone pain, jaw pain specifically associated with bisphosphonate use is more likely to be related to ONJ and requires further evaluation and management

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When planning care for an adolescent with anorexia nervosa, which nursing problem has the highest priority?

Correct Answer is C

Explanation

A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Correct Answer is C

Explanation

The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure?

The nurse is administering multiple prescribed vaccines to a toddler. Which strategy should the nurse prioritize to reduce the duration of pain?

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

The nurse-manager is involved in agency restructuring. During this re-engineering process, it is most important for the nurse to address which employee concern?

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The nurse is planning to administer two medications to a client at 0900. Which property of the drugs, if shared by both drugs, indicates a need to closely monitor the client for drug toxicity?