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 ["A","B","C","D"]

Explanation

Rationale

The client is experiencing significant psychological distress characterized by intrusive thoughts and memories related to the traumatic event (house collapsing during a hurricane). These thoughts are causing her difficulty in falling asleep and impacting her emotional well-being. Her statement about feeling unable to get out of a "funk" suggests that she may be experiencing symptoms of acute stress or post-traumatic stress disorder (PTSD). It's crucial to address her psychological distress promptly to provide support and prevent exacerbation of her symptoms.

Sleep Difficulties: The client requests sleeping medication due to her difficulty in falling asleep. Sleep disturbances are common after experiencing a traumatic event and can further contribute to emotional distress and hinder recovery. It's important to assess her sleep patterns and consider appropriate interventions, such as pharmacological sleep aids under medical supervision, to help her achieve adequate restorative sleep.

Environment: The client expresses a preference for a quieter area of the unit away from constant noise (talking and alarms). Hospital environments can be noisy and disruptive, which can exacerbate anxiety and sleep difficulties. Ensuring she is in a quieter environment or making adjustments to minimize noise near her can improve her comfort and facilitate better sleep, which is essential for recovery and emotional well-being.

A. Finish the procedure. B. Close the room door. C. Call for an assistant. D. Respond to the code.

Correct Answer is D

Explanation

Rationale

A. Continuing with the tracheostomy care procedure while a code blue is ongoing for another client is not appropriate. A code blue takes precedence as it indicates a life-threatening emergency requiring immediate response.

B. Closing the room door is not a priority action during a code blue. The immediate focus should be on responding to the emergency and providing assistance as needed.

C. If additional help is needed to assist with the tracheostomy care procedure, calling for an assistant could be appropriate under normal circumstances. However, during a code blue, the primary responsibility is to respond to the emergency immediately.

D. A code blue indicates a cardiac or respiratory arrest, which requires immediate intervention. As a nurse, responding to the code blue involves providing assistance with cardiopulmonary resuscitation (CPR), fetching emergency equipment, and supporting the healthcare team in resuscitative efforts.

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

Correct Answer is ["A","B","C","D"]

Explanation

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

Correct Answer is D

Explanation

A client admitted with pneumonia and on bedrest has not had the strength to perform self care. Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?

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

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?

Exhibits Which client statement(s) require(s) follow up teaching by the nurse? Select all that apply.

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

An older client with osteoarthritis reports increasing pain and stiffness in the right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of the symptoms?

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?