A nurse is caring for a client who has acute angina. Which of the following actions should the nurse take first?
Administer aspirin.
Measure blood pressure.
Administer nitroglycerin.
Initiate IV access.
The Correct Answer is C
Choice A reason: Administering aspirin is one of the first interventions for a client experiencing acute angina because aspirin has antiplatelet properties that help prevent blood clots, which can reduce the risk of a heart attack.
Choice B reason: Measuring blood pressure is important but not the first action to take. It provides valuable information about the cardiovascular status of the client and can influence further treatment decisions.
Choice C reason: Administering nitroglycerin is a priority action for acute angina as it helps to dilate the coronary arteries and relieve chest pain. However, it is typically administered after aspirin unless contraindicated.
Choice D reason: Initiating IV access is an important step in the management of acute angina, as it allows for the administration of medications and fluids if needed. However, it is not the first action to take during an acute angina episode.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A client with diabetes mellitus presenting with acute ketoacidosis does not necessarily require a private room unless there are other infection control concerns. Acute ketoacidosis is a metabolic complication of diabetes that can be managed in a general ward setting with appropriate medical care and monitoring.
Choice B reason: An older adult client admitted with aspiration pneumonia would benefit from a private room if the pneumonia is caused by an infectious agent that requires droplet or airborne precautions. However, aspiration pneumonia is often a result of inhaling food, stomach acid, or saliva into the lungs, and not always infectious.
Choice C reason: A client with a compound fracture of the right femur would require a private room if there is an associated risk of infection due to the open nature of the injury. However, standard precautions and wound care can often be managed in a semi-private or general ward setting unless there are specific infection control issues.
Choice D reason: A client reporting fever, night sweats, and cough for 2 days may be exhibiting symptoms of a communicable disease such as tuberculosis. This client would require a private room with airborne precautions to prevent the spread of infection to other patients and healthcare workers.
Correct Answer is D
Explanation
Choice A reason:A monthly calendar is often too complex and overwhelming for a client with Alzheimer’s. A single-day calendar or a daily schedule that can be marked off is much more effective for orientation.
Choice B reason: Providing plenty of stimulation can be overwhelming for clients with Alzheimer's disease. A calm and predictable environment is usually more beneficial.
Choice C reason: Keeping the room dark at night can promote sleep, but it is not the only consideration. A nightlight or low-level lighting can prevent falls if the client needs to get up during the night.
Choice D reason:When caring for a client with Alzheimer’s disease, the goal of nursing intervention is to maintain a safe, predictable environment that minimizes confusion and anxiety while maximizing the client's remaining functional abilities.
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