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. Keeping the drainage bag above waist level: The drainage bag should always remain below the level of the bladder to prevent backflow and infection.
B. Disconnecting the catheter from the drainage bag to empty the bag: The bag should not be disconnected, as this increases infection risk.
C. Using sterile gloves when emptying the drainage bag: Clean gloves (not sterile) are appropriate when emptying urine.
D. Emptying the drainage bag when it is half full: Emptying at the halfway point prevents backflow due to overfilling and ensures accurate urine output measurement.
Correct Answer is ["B","E"]
Explanation
A. Clients with C. difficile require dedicated equipment (e.g., thermometers, stethoscopes) that is not shared to prevent cross-contamination.
B. C. difficile is transmitted via spores that contaminate surfaces and clothing; a gown is required for contact precautions.
C. Alcohol-based hand rubs are ineffective against C. difficile spores. Hands must be washed with soap and water.
D. An N95 respirator is required only for airborne precautions (e.g., tuberculosis), not C. difficile.
E. Gloves must be changed after contact with infectious material and between procedures to prevent spore transmission.
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