A patient with a history of coronary artery disease experiences chest pain while walking. After taking sublingual nitroglycerin, the patient’s chest pain increases, and they experience clammy skin and blurry vision.

They call 911 and you are the nurse attending to them in the emergency department. What is the most important nursing intervention to do first?

Administer Lasix

Increase myocardial oxygenation

Obtain one hour of echocardiogram readings

Decrease the patient’s anxiety

Answer and Explanation

The Correct Answer is B

Choice A rationale
Administering Lasix (a diuretic) would not be the most immediate intervention for a patient experiencing increased chest pain after taking sublingual nitroglycerin. Lasix is used to treat fluid retention (edema) and swelling caused by congestive heart failure, liver disease, kidney disease, and other medical conditions. It works by causing the kidneys to get rid of unneeded water and salt from the body into the urine.
Choice B rationale
The most important nursing intervention for a patient experiencing increased chest pain after taking sublingual nitroglycerin would be to increase myocardial oxygenation. This can be achieved by administering supplemental oxygen and ensuring the patient is in a position that maximizes respiratory efficiency (such as semi-Fowler’s position). This intervention addresses the immediate life-threatening situation of myocardial ischemia.
Choice C rationale
Obtaining one hour of echocardiogram readings would not be the most immediate intervention for a patient experiencing increased chest pain after taking sublingual nitroglycerin. While an echocardiogram can provide valuable information about the structure and function of the heart, it is not the first step in managing acute chest pain.
Choice D rationale
Decreasing the patient’s anxiety is an important aspect of care, but it is not the most immediate intervention for a patient experiencing increased chest pain after taking sublingual nitroglycerin. The priority is to address the physical cause of the chest pain.

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Correct Answer is D

Explanation

Choice A rationale
Pulsus paradoxus, an exaggerated decrease in systolic blood pressure during inspiration, can be a sign of several conditions, including pericardial tamponade, constrictive pericarditis, and restrictive cardiomyopathy.
Choice B rationale
Exudate, a fluid with a high protein content that leaks out of blood vessels due to inflammation, is not typically associated with the symptoms described.
Choice C rationale
An aneurysm, a bulge or ballooning in a blood vessel, could potentially cause the symptoms described, but it is not the most concerning finding given the symptoms of edema, hepatomegaly, and muffled heart sounds.
Choice D rationale
Tamponade, a serious condition in which fluid or blood fills the pericardial sac, compressing the heart and preventing it from pumping effectively, could cause the symptoms described and would be the most concerning finding.

A. Venous thrombosis. B. Paresthesia. C. Vascular spasm. D. Arterial occlusion.

Correct Answer is D

Explanation

Choice A rationale
Venous thrombosis is a condition in which a blood clot forms in a vein, typically in the leg. While this condition can cause discomfort and changes in the appearance of the leg, it would not typically cause the leg to become cold and pale or result in the loss of a pulse.
Choice B rationale
Paresthesia refers to abnormal sensations in the body, such as tingling, numbness, or burning. While this condition could potentially cause discomfort, it would not typically cause the leg to become cold and pale or result in the loss of a pulse.
Choice C rationale
Vascular spasm is a sudden, brief tightening of the muscles inside the walls of a blood vessel. While this could potentially cause discomfort and changes in the appearance of the leg, it would not typically cause the leg to become cold and pale or result in the loss of a pulse.
Choice D rationale
Arterial occlusion is the correct answer. This condition involves a blockage in an artery, which can significantly reduce blood flow to the affected area. This could cause the leg to become cold and pale and result in the loss of a pulse.

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Naxlex Comprehensive Predictor Exams

A 56-year-old individual visits his primary care provider for a routine checkup.The physical examination reveals edema, an enlarged liver (hepatomegaly), and muffled heart sounds. Which of the following findings should the nurse be most concerned about?

Correct Answer is D

Explanation

An obese post-surgical patient reports sudden discomfort in her leg. Upon assessment, the nurse finds the leg to be cold and pale, with no pedal or popliteal pulse. What should the nurse suspect?

Correct Answer is D

Explanation

A patient who has been experiencing chest pain for several hours is admitted with a diagnosis of rule out acute myocardial infarction (AMI). Which laboratory test is most specific for the nurse to monitor in determining whether the patient has had an AMI?

A patient with severe pericarditis has developed a large pericardial effusion and is symptomatic. What type of procedure should the physician order to help treat this condition?

A 20-year-old female is being admitted to the hospital with fever and septic shock. Which set of assessment findings would the nurse expect the patient to exhibit?

A patient with heart failure has recently started taking Digoxin (Lanoxin), Furosemide (Lasix), and Captopril. Which finding by the home health nurse is a priority to communicate to the healthcare provider?

A nurse is caring for a patient who has undergone an angiogram. What should the nurse prioritize in assessing and documenting for this patient?

A patient with angina pectoris is experiencing chest pain at rest and needs to take three nitroglycerin (NTG) pills to relieve the pain. What should the nurse consider this as a major symptom of?

The nurse is administering nitroglycerin intravenously to alleviate chest pain. What is the therapeutic action of this medication?

When assessing a male patient in the telemetry unit who is experiencing persistent, crushing chest pain, which symptoms would lead the nurse to suspect a myocardial infarction?