Family members bring a client to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data?

The symptoms indicate an acute coronary episode and should be treated as such.

The symptoms indicate angina and should be treated as such.

Treatment should be determined pending the results of an exercise stress test.

The symptoms indicate a pulmonary etiology rather than a cardiac etiology.

Answer and Explanation

The Correct Answer is A

A. The symptoms indicate an acute coronary episode and should be treated as such:

The client's symptoms, including sudden midsternal chest pain unrelieved with rest and a history of coronary artery disease (CAD), strongly suggest an acute coronary event, such as a myocardial infarction (heart attack). Pale, cool skin can also be indicative of decreased perfusion due to cardiac compromise. Given these critical signs and symptoms, the nurse should interpret this as a potential cardiac emergency and initiate immediate interventions aimed at managing and stabilizing the client's condition.

B. The symptoms indicate angina and should be treated as such:

While angina can present with symptoms such as chest pain, it is typically relieved with rest or nitroglycerin. In contrast, the client in this scenario has midsternal chest pain that is not relieved with rest, which is more indicative of an acute coronary event like a myocardial infarction. Therefore, interpreting the symptoms as angina and treating them as such may not be appropriate given the severity and persistence of the chest pain.

C. Treatment should be determined pending the results of an exercise stress test:

Waiting for the results of an exercise stress test is not appropriate in this scenario, as the client's presentation suggests an acute cardiac event that requires immediate intervention. Exercise stress tests are typically used for diagnostic purposes to assess cardiovascular function under controlled conditions but are not suitable for managing acute coronary episodes or emergencies.

D. The symptoms indicate a pulmonary etiology rather than a cardiac etiology:

While some symptoms, such as shortness of breath or chest pain, can overlap between cardiac and pulmonary conditions, the client's presentation with sudden midsternal chest pain unrelieved with rest, pale cool skin, and a history of CAD strongly suggests a cardiac etiology, specifically an acute coronary event. It is essential to prioritize cardiac assessment and intervention based on the client's symptoms and medical history.

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Correct Answer is B

Explanation

A. Notify the blood bank of the discrepancy:

This choice suggests that there is a discrepancy between the blood type of the unit on hand (type B) and the client's blood type (type AB). However, in reality, there is no discrepancy in this case because individuals with type AB blood are universal recipients and can receive blood from donors of any blood type, including type B. Therefore, there is no need to notify the blood bank of any discrepancy.

B. Administer the blood as ordered:

This choice is the correct action. Type AB individuals are known as universal recipients because they can safely receive blood from donors of any blood type (A, B, AB, or O) without causing a major transfusion reaction. Since the client has type AB blood and the unit of blood on hand is type B, the nurse can administer the blood as ordered without concerns about blood type compatibility.

C. Complete an incident report:

Completing an incident report is typically done when an unexpected event or error occurs during patient care. In this scenario, there is no error or unexpected event related to blood type compatibility, so there is no need to complete an incident report.

D. Contact the provider for further orders:

Contacting the provider for further orders would be necessary if there were a specific reason or concern related to the blood transfusion that requires clarification or additional instructions. However, in this case, there are no issues with blood type compatibility, so contacting the provider is not necessary.

A. The test is noninvasive, and nothing will be inserted into the client's body. B. The client will remain on bed rest for 1 to 2 hours after the test. C. The client's pain will be managed aggressively during the procedure. D. The test will provide a detailed profile of the heart's electrical activity.

Correct Answer is A

Explanation

A. The test is noninvasive, and nothing will be inserted into the client's body: Transthoracic echocardiography (TTE) is a noninvasive procedure that uses ultrasound waves to create images of the heart. It involves placing a transducer on the chest wall to capture images of the heart's structure and function. The nurse should inform the client that no instruments or devices will be inserted into their body during the test.

B. The client will remain on bed rest for 1 to 2 hours after the test: This statement is not typically accurate for a TTE procedure. After a TTE, clients can usually resume their normal activities without any specific bed rest requirements, unless otherwise specified by the healthcare provider based on individual circumstances.

C. The client's pain will be managed aggressively during the procedure: TTE is generally a painless procedure that does not require aggressive pain management. The client may feel slight discomfort from the transducer's pressure on the chest, but it is typically well tolerated without the need for pain medication.

D. The test will provide a detailed profile of the heart's electrical activity: While echocardiography provides detailed images of the heart's structure and function, including information about blood flow and valve function, it does not directly assess the heart's electrical activity. For evaluating electrical activity, other tests such as electrocardiography (ECG or EKG) would be used.

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Family members bring a client to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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