The nurse enters her client’s room and finds the client complaining pf dyspnea, chest pain and syncope. The nurse assesses the client and notes the following findings. The client is pale and diaphoretic with a blood pressure of 90/60mmHg and respirations of 33. The client is anxious and fearing death. Which action should the nurse take first?

Administer oxygen via nasal cannula

Administer prescribed pain medications

Administer NS IV fluid

Ask the provider for a dopamine prescription

Answer and Explanation

The Correct Answer is A

A. Administer oxygen via nasal cannula: The client's symptoms of dyspnea, chest pain, syncope, and hypotension suggest a possible acute cardiovascular event, such as a myocardial infarction (MI) or pulmonary embolism (PE). Administering oxygen should be the priority to improve oxygenation and prevent hypoxia, which could exacerbate the client's symptoms and further compromise cardiac function.

B. Administer prescribed pain medications. Pain relief may be necessary, but stabilizing oxygen levels is the priority.

C. Administer NS IV fluid. Fluid administration may be helpful, but oxygenation is more critical in this situation to address the potential underlying respiratory or cardiac issue.

D. Ask the provider for a dopamine prescription. While dopamine may be used in cases of shock, the immediate action should be to ensure the client is adequately oxygenated.

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Correct Answer is B

Explanation

A. Decerebrate posturing: This involves extension and outward rotation of the arms, which is not observed here.

B. Decorticate posturing: Internal rotation, adduction, and flexion of the arms are characteristic of decorticate posturing, indicating damage to the corticospinal tract.

C. Flexion withdrawal: This refers to pulling away from a painful stimulus and does not involve the described pattern of movement.

D. Localization of pain: This is an intentional movement toward the source of pain, which is not demonstrated in this scenario.

A. ventricular aneurysm B. heart failure C. pulmonary embolism D. dysrhythmia

Correct Answer is D

Explanation

A. Ventricular aneurysm. Ventricular aneurysms are a complication that typically develops weeks or months after an MI.

B. Heart failure. While heart failure is a risk following an MI, it is more of a concern in the longer term after the acute phase.

C. Pulmonary embolism. Pulmonary embolism is not a direct complication of MI and is less common in the immediate post-MI period.

D. Dysrhythmia: Within the first 24 hours following a myocardial infarction, dysrhythmias, particularly ventricular arrhythmias, are common and can be life-threatening. This is the highest risk during the early period after MI.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a brain-injured client response to nail bed pressure. The client demonstrates internal rotation, adduction, and flexion of the arms, the nurse should report the response as which finding

Correct Answer is B

Explanation

A 55-year-old client who is diagnosed with an evolving myocardial infarction (MI) insists on going home. The nurse encourages the client to be admitted because he knows that within the first 24 hours of a MI, there is a high risk for which of the following?

Correct Answer is D

Explanation

A nurse is caring for client with increased intracranial pressure What is an appropriate nursing intervention for the client?

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The nurse is documenting a client’s assessment. The rhythm below was obtained from the client’s cardiac monitor. How should the nurse document this strip?

The nurse is providing discharge instructions to a 76-year-old male client with chronic atrial fibrillation who has a CHA2DS2-VASC score of 2. Which medication would the nurse identify as most likely to be prescribed for the client?

The nurse is educating a client diagnosed with mitral valve prolapse. What education will the nurse need to provide the client about this diagnosis? Possible Education

The nurse is evaluating a cardiac monitor strip for their client that displays a sinus rhythm with a heart rate of 72 bpm. The PR interval is 0.24 seconds. The vital signs are stable and the client reports no symptoms. What is the most appropriate nursing intervention?

A client with new onset right-sided weakness is admitted to the emergency department and the following orders are received. Which order should the nurse implement first?