A client with coronary artery disease (CAD) is admitted to the medical unit for testing. The client describes having had frequent episodes of angina over the last few days prior to admission. The client is now experiencing shortness of breath, nausea, and chest pressure. After obtaining the client's vital signs, which action should the nurse take next?

Verify troponin level assessments are scheduled every 3 to 6 hours for a series of three.

Initiate dim lighting, lower alarm volumes, and control traffic in and out of the room area.

Count and record the number of premature ventricular contractions per minute.

Apply oxygen via nasal cannula and titrate to keep oxygen saturation above 93%.

Answer and Explanation

The Correct Answer is D

Rationale

A. Troponin levels are cardiac biomarkers that are elevated in the blood when there is damage to the heart muscle, such as during a myocardial infarction (heart attack). Verifying the schedule for troponin assessments is important to monitor for myocardial damage and to guide treatment decisions.

B. This action is aimed at creating a quiet and calm environment for the client, which can help reduce anxiety and minimize stimuli that might exacerbate symptoms. Creating a conducive environment is beneficial for the client's comfort and well-being but should not delay urgent interventions required for acute symptoms.

C. PVCs are abnormal heartbeats that can occur in individuals with CAD and may indicate increased cardiac irritability or instability. While monitoring PVCs is important for assessing cardiac rhythm and potential complications, it is not the immediate priority over addressing acute symptoms such as shortness of breath, nausea, and chest pressure.

D. Oxygen therapy is essential in the management of a client with suspected ACS to improve oxygenation and reduce cardiac workload. Maintaining oxygen saturation above 93% helps ensure adequate tissue oxygenation, especially during episodes of chest discomfort and potential myocardial ischemia.

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Correct Answer is D

Explanation

A. This information is crucial as it provides insight into the client's abdominal assessment post- laparotomy. A soft abdomen with absent bowel sounds suggests normal bowel function has not yet returned, which is common after abdominal surgery. However, this does not have immediate postoperative implications.

B. A history of vomiting prior to surgery could indicate a gastrointestinal issue that may impact the client’s recovery or increase the risk of complications such as nausea and vomiting postoperatively.However, this history may not immediately affect the current postoperative care as much as some other findings (such as changes in bowel sounds or bleeding) in the acute postoperative period.

C. This information provides reassurance regarding circulation and mobility of the lower extremities. However, it may not be as urgent to report immediately unless there were concerns during surgery or potential complications related to positioning or circulation.

D.This should be reported to ensure that the client is receiving proper hydration and that their hydration status is carefully monitored. It’s especially important to monitor for dehydration or difficulties with oral intake following surgery.

A. Outreach for support group information. B. Domestic violence assistance. C. Blood pressure screening. D. Immunizations that are available.

Correct Answer is D

Explanation

Rationale

A. While support groups are important for individuals dealing with chronic illnesses or specific health issues, they are not directly related to primary disease prevention. Support groups focus more on coping, emotional support, and managing existing conditions rather than preventing diseases.

B. Domestic violence assistance is crucial for community health and safety, but it is not typically categorized under primary disease prevention. Domestic violence is a social issue that requires interventions aimed at prevention and support for victims, rather than preventing diseases through health promotion and education.

C. Blood pressure screening is an example of a primary disease prevention activity. High blood pressure (hypertension) is a significant risk factor for cardiovascular diseases such as heart attack and stroke. By screening individuals for hypertension, nurses can identify those at risk early and provide education on lifestyle modifications or medical interventions to prevent cardiovascular disease.

D. Immunizations are a cornerstone of primary disease prevention. Vaccines prevent infectious diseases by stimulating the immune system to produce immunity against specific pathogens. Community outreach programs that educate the public about immunizations help increase vaccination rates, thereby reducing the incidence of vaccine-preventable diseases in the population.

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?

Correct Answer is D

Explanation

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?

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