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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. The nurse should first implement the prescription of Cefazolin 1 gram intravenously every 6 hours.
This is because, on admission of a patient to the postanesthesia care unit (PACU) from surgery, the first priority is to assess the airway and breathing status. Administering Cefazolin, an antibiotic, helps prevent postoperative infections, which is crucial in the immediate postoperative period.
Correct Answer is A
Explanation
Choice A rationale
High-density lipoprotein (HDL) cholesterol is known as the “good” cholesterol because it helps remove other forms of cholesterol from your bloodstream. Higher levels of HDL cholesterol are associated with a lower risk of heart disease. Therefore, an HDL level of 85 mg/dL (2.2 mmol/L) is helpful in reducing cardiac risk.
Choice B rationale
Encouraging the client to reduce consumption of fatty foods is not necessary in this case as the client’s HDL level is already high, which is beneficial for heart health.
Choice C rationale
Asking the client about hereditary cardiac risk factors is not the most relevant action in this case. The client’s HDL level is already high, which is beneficial for heart health.
Choice D rationale
Explaining that the client may need medication therapy is not necessary in this case as the client’s HDL level is already high, which is beneficial for heart health.
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