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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale
Bradycardia, palpitations, confusion, and truncal rash are not typically associated with septic shock. Septic shock is a severe infection that occurs when bacteria enter the bloodstream. It can cause organs to fail and can lead to death.
Choice B rationale
Severe respiratory distress, jugular venous distention, and chest pain are more commonly associated with conditions like heart failure or pulmonary embolism, not septic shock.
Choice C rationale
Low blood pressure and tachycardia are common symptoms of septic shock. This happens because the body’s response to the infection causes blood vessels to dilate, which can lower blood pressure. The heart rate often increases (tachycardia) in an attempt to maintain blood flow to the organs.
Choice D rationale
Reduced cardiac output, increased systemic vascular resistance, and a moist cough are not typical symptoms of septic shock. These symptoms are more commonly associated with conditions like heart failure.

A. Keep your hands warm and wear gloves when handling cold objects. B. Avoid standing for prolonged periods. C. Maintain a regular exercise routine of about 30 minutes each day. D. Regularly return to the clinic for blood pressure checks.

Correct Answer is A

Explanation

Choice A rationale
Keeping hands warm and wearing gloves when handling cold objects is one of the most effective ways to manage Raynaud’s disease. Cold temperatures can trigger Raynaud’s attacks, which can cause the fingers to turn white, then blue, and feel cold and numb.
Choice B rationale
While avoiding standing for prolonged periods can be beneficial for certain conditions, it is not specifically related to managing Raynaud’s disease.
Choice C rationale
Regular exercise can help improve circulation, which can be beneficial for people with Raynaud’s disease. However, it’s not as crucial as keeping the hands warm.
Choice D rationale
Regularly returning to the clinic for blood pressure checks is not specifically related to managing Raynaud’s disease. While it’s important for individuals with certain conditions, such as hypertension, to regularly monitor their blood pressure, it’s not a key aspect of managing Raynaud’s disease.

View Question and Answer

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

A woman has recently been diagnosed with Raynaud’s disease. What important information should the nurse provide to this patient?

Correct Answer is A

Explanation

A client is admitted to the telemetry unit due to an episode of substernal chest pain. Diagnostic tests reveal an elevated ST segment on the electrocardiogram (ECG) and an increased cardiac troponin level. What would be an appropriate initial nursing intervention?

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?

Which antihypertensive medication is not recommended for patients with chronic obstructive pulmonary disease (COPD) and asthma?

Most cases of combined systolic and diastolic hypertension have no known cause and are documented on the chart as what type of hypertension?

The standard policy on the cardiac unit states, “Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg.”. Which patient should the nurse call the health care provider about?

A patient is being admitted to the emergency department with intermittent chest pain. They provide a list of daily medications. Which medication from the list has the most immediate implications for the patient’s care?

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?

After the shift change, which patient in the emergency department should the nurse prioritize for assessment?