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

The client with Addison's disease is experiencing weakness, confusion, and dehydration, which can be indicative of an adrenal crisis. The low sodium level (129 mEq/L) and low glucose level (54 mg/dl) further support this suspicion. An acute viral infection can trigger an adrenal crisis in individuals with Addison's disease.

Intravenous hydrocortisone, a glucocorticoid, is the treatment of choice for managing an adrenal crisis. It helps to replenish cortisol levels and stabilize the client's condition.

Hydrocortisone helps in restoring the body's stress response and regulating electrolyte and glucose levels.

A broad-spectrum antibiotic may be necessary if there is evidence of a bacterial infection, but it does not directly address the symptoms associated with Addison's disease.

Regular insulin is used for managing high blood glucose levels in conditions such as diabetes, but in this case, the client has low glucose levels, so insulin is not the appropriate intervention.

Potassium chloride is a medication used to treat low potassium levels (hypokalemia), but the client's potassium level is within the reference range (5.3 mEq/L). Therefore, potassium chloride is not indicated in this situation.

A. Side-lying with the head slightly elevated. B. Standing with the head leaning backward. C. Sitting up and leaning forward. D. Supine with the legs raised.

Correct Answer is C

Explanation

A) Incorrect- This position is not ideal for managing a nosebleed because it does not promote drainage and may lead to blood flowing down the throat.
B) Incorrect- Leaning the head backward can cause blood to flow down the throat and may lead to choking or aspiration.
C) Correct- Placing the child in a sitting position and leaning forward helps prevent blood from flowing down the back of the throat, which can lead to choking or aspiration. Leaning forward allows the blood to drain out through the nostrils.
D) Incorrect- Placing the child in a supine position with raised legs is not recommended for managing a nosebleed, as it may lead to blood flowing down the throat.

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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

Correct Answer is C

Explanation

The school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In which position should the nurse place the child?

Correct Answer is C

Explanation

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having had prior sexually transmitted infections. Which response should the nurse provide?

A client with diabetes insipidus (DI) has an average urinary output of 500 ml. of dilute urine every hour for the last 4 hours. Which laboratory test is most important for the nurse to monitor?

A client with a history of lung cancer reluctantly comes to the clinic because of persistent hoarseness and a chronic cough. The client's respirations are labored when speaking and the capillary refill is 3 seconds. Which additional finding warrants intervention by the nurse?

An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions in a clear manner. Which action should the nurse implement first?

When caring for a client with full-thickness burns to both lower extremities, which assessment finding(s) warrant immediate intervention by the nurse? (Select all that apply.)

The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement?

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

Patient Data What other treatments might be helpful for this client? Select all that apply.