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A nurse is caring for a client in the emergency department (ED). The client presents with substernal chest pain that comes and goes.

  • The client states that the pain has been occurring for the last 6 hours.
  • The pain, at times, radiates down the left arm.
  • The client also reports intermittent nausea.
  • The client appears pale and slightly diaphoretic.
  • The client rates current pain as 8 on a scale of 0 to 10. The nurse is planning care for the client.

For each potential prescription, indicate whether it is indicated, nonessential, or contraindicated.

A.

Administer oxygen to maintain oxygen saturation greater than 94%.

B.

Prepare the client for intubation.

C.

Apply continuous ECG monitoring.

D.

Obtain the client’s family history.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"}}

Choice A - Indicated:

  • Administering oxygen to maintain oxygen saturation >94% is recommended in suspected acute coronary syndrome (ACS) to prevent myocardial hypoxia.
  • Oxygen therapy is not routinely given if SpO₂ is ≥94%, but if there are signs of hypoxia, respiratory distress, or low saturation, it is appropriate.

Choice B - Contraindicated:

  • Intubation is not indicated unless the patient has severe respiratory distress or impending respiratory failure.
  • This client is not in respiratory failure (no severe dyspnea, altered consciousness, or worsening hypoxia).

Choice C - Indicated:

  • Continuous ECG monitoring is essential in suspected ACS to detect arrhythmias, ischemia, and ST changes.
  • ECG findings will guide early intervention, including medication administration (e.g., aspirin, nitroglycerin) or reperfusion therapy.

Choice D - Nonessential:

  • Family history of cardiovascular disease is important for risk assessment but is not a priority in an acute setting.
  • While it can help with long-term management, immediate interventions (oxygen, ECG, medications) take precedence.


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Related Questions

Correct Answer is D

Explanation

Choice A rationale

Antiembolic stockings compress superficial veins, which may further limit blood flow to the already compromised peripheral arteries, exacerbating symptoms of peripheral arterial disease rather than alleviating them.

Choice B rationale

Elevating the legs above heart level reduces arterial perfusion to the extremities. In peripheral arterial disease, maintaining a position that allows gravity to assist arterial flow is beneficial, not restricting it.

Choice C rationale

Applying heat can dilate blood vessels and increase blood flow; however, it can also increase the risk of burns due to decreased sensation and poor skin integrity commonly seen in peripheral arterial disease patients.

Choice D rationale

A warm environment helps to prevent vasoconstriction. Cold temperatures can cause the arteries to constrict, reducing blood flow to the extremities. A consistent warm environment supports improved blood circulation.

Correct Answer is A

Explanation

Choice A rationale

Intermittent claudication, characterized by muscle pain during exercise relieved by rest, indicates early-stage peripheral arterial disease due to decreased blood flow. It is an early symptom resulting from insufficient oxygen supply to muscles.

Choice B rationale

Rest pain occurs in more advanced peripheral arterial disease and indicates critical limb ischemia. It is a late-stage symptom, usually present even at rest due to severely compromised blood flow.

Choice C rationale

Foot ulcers are signs of advanced peripheral arterial disease, often developing due to poor circulation and delayed wound healing. These ulcers indicate severe disease progression and significant arterial insufficiency.

Choice D rationale

Dependent rubor, a red discoloration of the skin when the leg is lowered, occurs in advanced peripheral arterial disease. It results from chronic ischemia and dilatation of the small blood vessels in response to prolonged tissue hypoxia.

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