A nurse is assessing a client who has been admitted with chest pain.
Which of the following findings should the nurse report to the provider immediately?
The client has a history of hypertension and diabetes.
The client rates the pain as 8 on a scale of 0 to 10.
The client has crackles in the lower lobes of both lungs.
The client has an elevated troponin level in the blood.
The Correct Answer is D
D) The client has an elevated troponin level in the blood.
Rationale: An elevated troponin level indicates myocardial damage and is a diagnostic marker for acute coronary syndrome (ACS), which includes unstable angina and myocardial infarction (MI). This is a life-threatening condition that requires immediate intervention.
A) The client has a history of hypertension and diabetes. - This is an important finding, as hypertension and diabetes are risk factors for cardiovascular disease, but it is not an urgent finding that requires immediate reporting.
B) The client rates the pain as 8 on a scale of 0 to 10. - This is a significant finding, as chest pain is a cardinal symptom of ACS, but it is not a definitive finding that confirms the diagnosis.
C) The client has crackles in the lower lobes of both lungs. - This is an abnormal finding, as crackles indicate fluid accumulation in the alveoli, which may be caused by heart failure, pneumonia, or pulmonary edema. However, it is not a specific finding for ACS and may be related to other conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should ask open-ended questions that cover the characteristics, duration, frequency, severity, precipitating and relieving factors, associated symptoms, and impact of the cough on the client's health and quality of life.
Incorrect options:
A) "How long have you had this cough?" - This is a correct question, but it is not the only question that should be asked.
B) "What do you think is causing your cough?" - This is a correct question, but it is not the only question that should be asked.
C) "How does your cough affect your daily activities?" - This is a correct question, but it is not the only question that should be asked.
Correct Answer is B
Explanation
Inspection, auscultation, percussion, palpation
Rationale: The correct order of techniques for abdominal assessment is inspection, auscultation, percussion, and palpation. This order prevents altering bowel sounds by manipulating the abdomen before listening to them.
Incorrect options:
A) Inspection, palpation, percussion, auscultation - This order may alter bowel sounds by palpating and percussing before auscultating them.
C) Auscultation, inspection, palpation, percussion - This order may miss visual cues by inspecting after auscultating.
D) Palpation, auscultation, inspection, percussion - This order may alter bowel sounds and miss visual cues by palpating before auscultating and inspecting.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.