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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. While bleeding can occur postoperatively from the catheter insertion site, it is more indicative of venous or capillary bleeding rather than arterial obstruction. Arterial obstruction typically presents with signs related to decreased arterial blood flow rather than external bleeding.

B. This finding suggests a difference in peripheral pulses between the two lower extremities. While it could indicate arterial compromise, the question specifically asks about arterial obstruction at the site of the catheterization (right femoral artery).

C. This finding is concerning for arterial obstruction. Coolness, pallor, and blanching of the right foot indicate decreased arterial blood flow to the extremity. Arterial obstruction can lead to reduced perfusion distal to the occlusion site, resulting in these clinical signs.

D. These vital sign changes could indicate systemic complications, such as shock, rather than isolated arterial obstruction at the femoral artery site. While systemic changes can occur secondary to arterial obstruction, they are not specific indicators of obstruction at the femoral artery.

A. Reduce the client's interaction with others during the day. B. Clarify reality with the client about delusional thoughts. C. Awaken the client earlier for daily morning care. D. Use distraction and therapeutic communication skills.

Correct Answer is D

Explanation

Rationale

A. This approach might inadvertently increase feelings of isolation and worsen agitation. Older adults with dementia often benefit from social interaction and engagement. Limiting interaction could lead to increased confusion and behavioral issues.

B. Attempting to correct or argue with the client about their delusions is generally not effective and can escalate agitation. Clients with dementia may not have the cognitive ability to understand or accept reality as others perceive it. Therefore, trying to clarify or correct delusional thoughts is unlikely to be helpful and may increase distress.

C. While maintaining a consistent routine is beneficial for clients with dementia, forcibly awakening the client earlier could disrupt their natural sleep patterns and contribute to increased confusion and agitation. It's important to balance the need for routine with the client's individual sleep and rest patterns.

D. This approach focuses on redirecting the client's attention away from the distressing thoughts and behaviors. Distraction techniques involve engaging the client in activities or topics that they find enjoyable or comforting. Therapeutic communication skills include active listening, empathy, and validating the client's emotions without reinforcing delusions.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

Correct Answer is C

Explanation

An older adult client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) to assist in bathing, is becoming increasingly agitated and stating the UAP "wants to hurt me and tie me up." Which approach should the nurse use with the client?

Correct Answer is D

Explanation

A client with metastatic cancer who was taking hydromorphone PO at home is now receiving the medication IV while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete?

When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? Select all that apply.

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

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

A client taking temazepam informs the nurse of plans to quit taking the medication due to feelings of "hungover" the next day. Which action should the nurse implement?

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress,

When preparing a client for an intravenous pyelogram (IVP), it is essential for the nurse to take which action?

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?