A nurse in the emergency department is caring for a client.
The nurse reviews the client’s medical record. Select the 4 actions the nurse should take.
Request a prescription for a sputum culture.
Perform a 12-lead ECG.
Prepare to administer antiplatelet therapy.
Obtain arterial blood gases.
Prepare the client for a cardiac catheterization.
Administer oxygen at 2 L/min nasal cannula.
Correct Answer : B,C,E,F
A. Sputum cultures are indicated for suspected respiratory infections, not myocardial infarction. This is incorrect.
B. A 12-lead ECG is the first diagnostic test for chest pain to identify ST-segment elevation or ischemic changes indicating myocardial infarction.
C. Antiplatelet therapy (e.g., aspirin) prevents further platelet aggregation and thrombus formation, which improves coronary blood flow during acute coronary syndromes.
D. ABGs may provide information about oxygenation, but are not routinely required unless severe respiratory compromise or acidosis is suspected. Priority is oxygen and cardiac assessment.
E. Preparing for cardiac catheterization (coronary angiography) is appropriate since this client shows positive troponins and unrelieved chest pain, indicating myocardial infarction requiring reperfusion evaluation.
F. Oxygen administration at 2 L/min via nasal cannula helps improve oxygenation (SpO₂ 89%) and reduces myocardial ischemia. Maintaining SpO₂ ≥ 90% is essential to minimize cardiac workload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The nurse uses gloves when administering an enema: Gloves should always be worn to prevent exposure to body fluids.
B. The nurse positions a client who is postoperative in a semi-fowler's position: This position promotes lung expansion and reduces aspiration risk.
C. The nurse applies a cold compress to reduce localized swelling: Cold compresses reduce swelling and pain from inflammation.
D. The nurse performs auscultation of the lungs without lifting the gown: Auscultation should be performed on bare skin to ensure accurate assessment of breath sounds, as clothing can muffle or distort findings.
Correct Answer is C
Explanation
A. Orthotic devices, such as braces or splints, help maintain mobility and prevent injury. They should not be avoided; they enhance safety and stability.
B. Walking with feet close together decreases balance and increases fall risk. Clients with MS should widen their stance to improve stability.
C. Using a cane provides support, balance, and stability, reducing the risk of falls due to muscle weakness or incoordination. Adaptive devices allow clients to maintain independence safely.
D. A “rigorous” exercise plan can cause fatigue and worsen MS symptoms. Moderate, balanced exercise with rest periods is recommended.
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