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.

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Free Nursing Study Resources

Correct Answer is []

Explanation

Based on the information provided, the client is most likely experiencinganorexia nervosa.This is suggested by her significant weight loss, bradycardia, hypothermia, lanugo-type hair, and her expressed fear of gaining weight despite being underweight. However, this is a preliminary assessment and a definitive diagnosis should be made by a healthcare professional.

Actions the nurse should take to address this condition include:

Acknowledge anxious feelings: It’s important to validate the client’s feelings and fears about food and weight gain.This can help build trust and facilitate further discussion about her health.
Provide emotional support: Emotional support is crucial in managing eating disorders.The nurse can provide reassurance, listen empathetically, and encourage the client to express her feelings.

Parameters the nurse should monitor to assess the client’s progress include:

Nutritional intake: Monitoring the client’s food and fluid intake can help assess her nutritional status and response to treatment.
Weight and BMI: Regular monitoring of the client’s weight and BMI can provide objective measures of her nutritional status and response to treatment.

A. Administer a stool softener B. Ask the client about their normal bowel routine C. Hold the client's next meal D. Perform a digital rectal exam E. Discontinue morphine

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

Explanation

.Administer a stool softener: This could be a good option to consider, as the client has not had a bowel movement since the surgery. However, the nurse should first consult with the healthcare provider before administering any new medications.

B.Ask the client about their normal bowel routine: This is a good action to take. Understanding the client’s normal bowel routine can provide valuable context for the current situation.

C.Hold the client’s next meal: This may not be necessary at this point. The client’s regular diet has been ordered by the provider, and there’s no indication of nausea, vomiting, or other symptoms that would necessitate holding meals.

D.Perform a digital rectal exam: This could be considered if there’s a concern about impaction or other complications. However, this should only be done after consulting with the healthcare provider.

E.Discontinue morphine: This is not advisable based on the information provided. The client is reporting uncontrolled pain, and morphine has been ordered by the provider for pain management. Any changes to pain medication should be discussed with the healthcare provider.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

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

Explanation

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

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 The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.

The nurse is preparing a client for an outpatient thoracentesis.Which statement made by the client indicates a need for additional education?

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye.Which action should the nurse take?