A patient with coronary artery disease (CAD) is admitted to the medical unit for testing.
The patient reports frequent episodes of angina over the past few days and is currently experiencing shortness of breath, nausea, and chest pressure.
After obtaining the patient’s vital signs, what should be the nurse’s next course of action?

Count and record the number of premature ventricular contractions per minute.

Apply oxygen via nasal cannula and adjust to maintain oxygen saturation above 93%.

Ensure troponin level assessments are scheduled every 3 to 6 hours for a series of three.

Initiate dim lighting, lower alarm volumes, and control traffic in and out of the room area.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Counting and recording the number of premature ventricular contractions per minute is not the immediate priority for a patient experiencing symptoms of angina and shortness of breath. While it is important to monitor the patient’s heart rhythm, the immediate priority is to address the patient’s symptoms and stabilize their condition.

Choice B rationale

Applying oxygen via a nasal cannula and adjusting to maintain oxygen saturation above 93% is the immediate priority for a patient experiencing symptoms of angina and shortness of breath. Oxygen therapy can help to relieve the symptoms of angina and improve the patient’s oxygen saturation.

Choice C rationale

Ensuring troponin level assessments are scheduled every 3 to 6 hours for a series of three is important for diagnosing a heart attack, but it is not the immediate priority. The immediate priority is to address the patient’s symptoms and stabilize their condition.

Choice D rationale

Initiating dim lighting, lowering alarm volumes, and controlling traffic in and out of the room area can help to create a calm and quiet environment for the patient. However, this is not the immediate priority. The immediate priority is to address the patient’s symptoms and stabilize their condition.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","C","D","E"]

Explanation

Choice A rationale

Listening for bilateral breath sounds is a common method to confirm the correct placement of the ETT1. When the ETT is correctly placed, breath sounds should be heard equally on both sides of the chest.

Choice B rationale

Verifying a capillary refill time of less than 3 seconds is not directly related to confirming the placement of an ETT. Capillary refill time is often used to assess peripheral circulation and hydration status, not airway management.

Choice C rationale

Checking that the ETT markings are between 22 and 26 cm at the teeth line is another method to confirm correct ETT placement. These markings help ensure that the ETT is not too far into the trachea, which could cause one lung to be ventilated more than the other.

Choice D rationale

Observing for symmetrical chest movement is a visual confirmation of correct ETT placement. When the ETT is correctly placed, both sides of the chest should rise and fall equally with each breath.

Choice E rationale

Arranging for a portable chest x-ray is considered the gold standard for confirming ETT location. It provides a visual confirmation that the ETT is in the trachea and not in the esophagus.

A. Assist the client to the bathroom. B. Have an opioid agonist at the bedside. C. Provide oral care at least twice a day. D. Assess mental status regularly. E. Monitor calcium levels. F. Screen for orthostatic hypotension.

Correct Answer is ["A","D","F"]

Explanation

Choice A rationale

Assisting the client to the bathroom is appropriate as clonazepam can cause dizziness and unsteadiness, increasing the risk of falls.

Choice B rationale

Having an opioid agonist at the bedside is not necessary for a client starting clonazepam. Clonazepam is a benzodiazepine, not an opioid.

Choice C rationale

Providing oral care at least twice a day is generally good practice for all patients, but it’s not specifically related to clonazepam use.

Choice D rationale

Assessing mental status regularly is crucial as clonazepam can cause changes in mood and behavior.

Choice E rationale

Monitoring calcium levels is not typically required for a client starting clonazepam.

Choice F rationale

Screening for orthostatic hypotension is important as clonazepam can lower blood pressure, leading to dizziness and fainting when the client stands up.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A young adult is admitted to the emergency department after consuming an unknown quantity of drugs.The patient is unresponsive, and an endotracheal tube (ETT) has been inserted.What methods should the nurse use to confirm the correct placement of the ETT? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

What nursing interventions are appropriate for a client starting clonazepam? Select all that apply.

Correct Answer is ["A","D","F"]

Explanation

An elderly patient who had a fall at a store is admitted with a potential right hip fracture.What assessment finding should the nurse report to the healthcare provider?

Exhibits Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

A client admitted with pneumonia and on bedrest has not had the strength to perform self-care.Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?

A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines.Which instruction should the nurse provide the parent about care of the infant after the injections?

The nurse is assessing a 4-year-old patient with eczema. The child’s skin is dry and scaly, and the parent reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. What guideline is indicated for care of this child?

While changing a postoperative patient’s dressing, the nurse notices purulent drainage at the site.Before reporting this to the healthcare provider, which of the patient’s lab values should the nurse check?

Exhibits For each statement, specify if the client has an understanding or no understanding of asthma triggers. Each row must have one option selected.

A patient admitted with an acute coronary syndrome (ACS) is receiving eptifibatide, a glycoprotein (GP) IIb IIIa inhibitor.Which assessment finding poses the greatest risk to the patient?