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 D
Explanation
The correct answer is Choice D.
Choice D rationale: Keeping the nails trimmed short is crucial for a child with eczema because it minimizes the damage done when the child scratches their skin. Short nails reduce the risk of breaking the skin and causing infections or further irritation, which can exacerbate eczema symptoms. This preventive measure helps maintain the skin's integrity and reduces the risk of secondary infections.
Choice A rationale: Allowing the child to wear only 100% cotton clothing can help reduce skin irritation as cotton is a soft, breathable fabric. However, it is not as directly related to preventing the harm caused by scratching.
Choice B rationale: Applying baby lotion to the skin can help keep the skin moisturized, but it might not be sufficient for eczema management. A more intensive emollient or specific eczema treatment may be needed.
Choice C rationale: Bathing the child daily with bath oil can help moisturize the skin, but over-bathing can sometimes exacerbate eczema. It's important to use gentle, non-irritating bath products and to follow other guidelines, such as trimming nails.
Correct Answer is B
Explanation
Choice A rationale
Hematocrit is a measure of the proportion of red blood cells in the blood. While it can be affected by various conditions, it is not the most relevant lab value to check when purulent drainage is noticed at a postoperative patient’s dressing site.
Choice B rationale
Neutrophil count is a measure of the number of neutrophils, a type of white blood cell, in the blood. An elevated neutrophil count can indicate an infection, making it the most relevant lab value to check in this scenario.
Choice C rationale
Platelet count is a measure of the number of platelets in the blood. While platelets play a crucial role in blood clotting, they are not directly related to infection and therefore not the most relevant lab value to check in this scenario.
Choice D rationale
Serum sodium level is a measure of the amount of sodium in the blood. While it can be affected by various conditions, it is not the most relevant lab value to check when purulent drainage is noticed at a postoperative patient’s dressing site.
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