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. 50 mL/hr urine output is adequate and indicates proper renal perfusion.
B. Pain level of 2 shows effective pain control.
C. O₂ saturation of 96% on 2 L/min nasal cannula is acceptable postoperatively.
D. A saturated postoperative dressing indicates active bleeding and possible hemorrhage, a life-threatening complication that must be reported immediately.
Correct Answer is B
Explanation
A. Tenting of the skin suggests dehydration, not fluid overload.
B. A respiratory rate of 30/min indicates tachypnea, which can occur due to pulmonary congestion and decreased gas exchange from fluid overload. Other signs may include crackles, dyspnea, elevated blood pressure, and jugular vein distension.
C. A heart rate of 60/min is normal; fluid overload typically causes tachycardia as the body compensates for increased volume and decreased oxygenation.
D. Warm, dry skin is a normal finding and does not indicate excess fluid volume.
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