A nurse is assisting with the care of a client in the emergency department who reports severe radiating chest pain and shortness of breath. The client appears restless, frightened, and slightly cyanotic. The provider prescribes oxygen by nasal cannula at 4 L/min stat, cardiac enzyme levels, IV fluids, and a 12-lead ECG. Which of the following actions should the nurse take first?

Attach the leads for a 12-lead ECG.

Obtain a blood sample.

Initiate oxygen therapy.

Insert the IV catheter.

Answer and Explanation

The Correct Answer is C

Choice A reason: While attaching leads for a 12-lead ECG is important, it is not the most immediate action required for a client showing signs of distress and potential hypoxia.

Choice B reason: Obtaining a blood sample is necessary for diagnosing the cause of chest pain but is not the first priority in an emergency situation.

Choice C reason: Initiating oxygen therapy is the first and most critical step in managing a client with severe chest pain, shortness of breath, and cyanosis to ensure adequate oxygenation.

Choice D reason: Inserting an IV catheter is important for administering medications and fluids but comes after ensuring the client is receiving sufficient oxygen.

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Correct Answer is B

Explanation

Choice A reason: While all individuals can develop heart failure, an Asian male is not considered the highest risk group based on the available data.

Choice B reason: A Black female is at a higher risk for developing heart failure, especially due to factors like hypertension, diabetes, and certain socioeconomic factors³.

Choice C reason: A Hispanic female may have multiple risk factors for heart failure, but the prevalence and risk are not as high as in the Black female population³.

Choice D reason: A White male, while at risk for heart failure, does not have the highest risk when compared to a Black female with the same age and health conditions³.

A. Respiratory alkalosis B. Metabolic acidosis C. Respiratory acidosis D. Metabolic alkalosis

Correct Answer is C

Explanation

Choice A reason: Respiratory alkalosis is typically associated with hyperventilation, which is not common in acute pulmonary edema.

Choice B reason: Metabolic acidosis can occur in pulmonary edema due to tissue hypoxia and lactic acid production, but respiratory acidosis is more directly related to the primary problem of gas exchange.

Choice C reason: Respiratory acidosis is likely in acute pulmonary edema due to impaired gas exchange and CO2 retention.

Choice D reason: Metabolic alkalosis is not typically associated with acute pulmonary edema and is less likely than respiratory acidosis in this context.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a group of patients. Which patient is at the highest risk for developing heart failure (HF)?

Correct Answer is B

Explanation

A nurse is assisting in the care of a client who has acute onset pulmonary edema and is experiencing dyspnea with low oxygen saturation rates. The nurse should recognize the client is at risk for which of the following acid-base imbalances?

Correct Answer is C

Explanation

The licensed practical nurse is assisting with collecting data on a female patient. Which of the following findings should be reported to the registered nurse as possible atypical symptoms of a myocardial infarction in the absence of chest pain? Select all that apply.

Ms. S is admitted to your medical unit with a diagnosis of dehydration and a history of depression. She tells you, "I just can't eat, I'm not hungry." What would be your best therapeutic response?

Which statement made by a patient indicates a possible exacerbation of heart failure (HF)?

Your patient, who is manic, has lost 5 pounds and is underweight. Which meal is most appropriate?

A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. Which of the following is an appropriate food choice for this client?

The nurse is reinforcing teaching to the patient about the cause of pain from coronary artery disease. The nurse would evaluate the patient as understanding the education if the patient stated which of the following causes the pain from coronary artery disease?

A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first?

A newly licensed nurse is assisting with the involuntary admission of a client who has depression to an acute care mental health facility. Which of the following guidelines should the nurse follow when caring for the client?