Scenario:

A 45-year-old female client is admitted to the emergency department with complaints of sudden shortness of breath and chest tightness. She has a history of hypertension and diabetes.

Exhibits

A nurse is assessing the client at 0700 hrs. Which of the following actions should the nurse take first? A Initiate a cardiac enzyme panel

Initiate a cardiac enzyme panel

Start intravenous fluid therapy

Provide pain relief medication

Obtain an electrocardiogram (ECG)

Perform a comprehensive physical assessment

Answer and Explanation

The Correct Answer is D

Choice A rationale: Initiating a cardiac enzyme panel can help determine if the client has had a heart attack. However, this is not the immediate priority. The client’s symptoms suggest a possible cardiac event, which needs to be addressed first. An ECG can provide immediate information, while a cardiac enzyme panel takes longer to return results.

Choice B rationale: Starting intravenous fluid therapy may be necessary depending on the client’s hydration status and overall condition. However, it is not the immediate priority. The client’s symptoms suggest a possible cardiac event, which needs to be addressed first.

Choice C rationale: Providing pain relief medication may be necessary if the client is in pain. However, the client’s primary complaint is chest tightness and difficulty breathing, not pain. Therefore, addressing the potential cardiac issue is the priority.

Choice D rationale: The client’s symptoms of sudden shortness of breath, chest tightness, and anxiety, along with her history of hypertension and diabetes, are concerning for a possible cardiac event. An electrocardiogram (ECG) can provide immediate information about the heart’s electrical activity and help identify if the client is experiencing a heart attack or other cardiac event. This should be the first action taken to quickly identify the cause of the client’s symptoms and initiate appropriate treatment.

Choice E rationale: Performing a comprehensive physical assessment is an important part of nursing care. However, in this situation, the client’s symptoms indicate a need for immediate intervention to address her potential cardiac issue.

Choice F rationale: Monitoring the client’s blood glucose levels is important given her history of diabetes. However, this is not the immediate priority. The client’s symptoms suggest a possible cardiac event, which needs to be addressed first.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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

Explanation

Choice A rationale

The blood pressure of 114/86 mm Hg is within the normal range and does not require follow- up.

Choice B rationale

The oxygen saturation of 85% on room air is below the normal range of 95% to 100%, indicating the client may be experiencing hypoxemia, which requires follow-up.

Choice C rationale

The temperature of 38.6C (101.5° F) is slightly elevated, indicating the client may have a fever, which requires follow-up.

Choice D rationale

The heart rate of 99/min is slightly elevated, indicating the client may be experiencing tachycardia, which requires follow-up.

A. Admitting diagnosis B. Breath sounds C. Body temperature D. Diagnostic test results

Correct Answer is B

Explanation

When giving a change-of-shift report about a client with pneumonia, the priority piece of information for the nurse to provide is the client’s breath sounds. This is because breath sounds can indicate the severity of the pneumonia and the effectiveness of the treatment. Changes in breath sounds can signal a worsening condition that requires immediate medical attention.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has COPD.The following are the client’s vital signs: Temperature 38.6C (101.5° F), BP 114/86 mm Hg, Heart rate 99/min, Respiratory rate 32/min, Oxygen saturation 85% on room air.Which three findings require follow-up?

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

Explanation

A nurse is giving a change-of-shift report about a client they admitted earlier that day who has pneumonia. Which piece of information is the priority for the nurse to provide?

Correct Answer is B

Explanation

A nurse is documenting a client’s fluid intake over the past 8 hours. Which of the following items should be recorded as 120 mL of fluid in the client’s intake and output record?

A nurse is providing care for a patient who has terminal liver cancer.Which statement from the patient should the nurse recognize as a sign of spiritual distress?

A nurse is caring for a patient who has a respiratory infection.What technique should the nurse use when performing nasotracheal suctioning for the patient?

A nurse is performing a skin assessment for a client who expresses concern about skin cancer.Which of the following findings should the nurse identify as a potential indication of a skin malignancy?

A nurse responds to a call light and finds a patient lying on the bathroom floor. What should the nurse do first?

A nurse is educating a terminally ill patient about declining resuscitation in a living will.The patient asks, “What would happen if I arrived at the emergency department and I had difficulty breathing?” Which of the following responses should the nurse make?

A client in the emergency department reports abdominal pain and has not had a bowel movement for the past 7 days. Based on the client’s clinical findings, which action should the nurse take?

A nurse is about to administer an injection of an opioid medication to a patient. The nurse has drawn 1 mL of the medication from a 2 mL vial.What should the nurse do next?