The nurse is caring for a client with a history of coronary artery disease who reports waking up with a sudden onset of vise-like chest pressure.
The client reports that the pain decreases at rest but continues to feel a constant mid-chest pressure. What intervention should the nurse perform in the immediate management of the client?
What intervention should the nurse perform in the immediate management of the client?
Determine the presence of ST-elevations or non-ST-elevations on the electrocardiogram
Initiate dim lighting, lower alarm volumes, and control traffic in and out of the room area
Verify troponin level assessments are scheduled every 3-6 hours for a series of three
Apply oxygen via nasal cannula and titrate to keep oxygen saturation above 93%
The Correct Answer is D
Choice A rationale
Determining the presence of ST-elevations or non-ST-elevations on the electrocardiogram is an important step in diagnosing a myocardial infarction. However, this is typically performed by a healthcare provider or a trained technician, not a nurse.
Choice B rationale
While creating a calm and quiet environment can be beneficial for a client experiencing chest pain, it is not the immediate intervention that should be performed. The client’s symptoms suggest a possible cardiac event, which requires immediate medical intervention.
Choice C rationale
Verifying that troponin level assessments are scheduled every 3-6 hours for a series of three is important for diagnosing myocardial infarction. However, this is not the immediate intervention that should be performed. The client’s symptoms suggest a possible cardiac event, which requires immediate medical intervention.
Choice D rationale
Applying oxygen via nasal cannula and titrating to keep oxygen saturation above 93% is the correct intervention. This action helps to increase the oxygen supply to the myocardium, potentially decreasing the extent of myocardial damage and relieving chest pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.8"]
Explanation
Step 1: Convert the client’s weight from pounds to kg. 1 kg is approximately 2.2 lbs. So, 176 lbs
÷ 2.2 = 80 kg (rounded to the nearest whole number).
Step 2: Calculate the total mg of enoxaparin sodium needed per day. The prescription is for 1.5 mg/kg/day. So, 80 kg × 1.5 mg/kg/day = 120 mg/day.
Step 3: Calculate the mL of enoxaparin sodium needed. The medication is available in a 120 mg/0.8 mL prefilled syringe. So, 120 mg ÷ 120 mg/0.8 mL = 0.8 mL. The nurse should administer 0.8 mL.
Correct Answer is A,D,B,C
Explanation
- Complete a focused assessment: The first step in managing a patient with abdominal pain and other symptoms is to perform a comprehensive assessment. This will help identify the cause of the symptoms and guide subsequent interventions.
- Offer PRN pain medication: Once the immediate risks have been addressed, managing the patient’s pain is a priority. However, the choice of pain medication will depend on the results of the assessment.
- Send the emesis sample to the lab: Sending the emesis sample to the lab can provide valuable information about the cause of the patient’s symptoms. However, this is not as urgent as the other interventions.
- Elevate the head of the bed: Elevating the head of the bed can help reduce the risk of aspiration, especially in a patient who has vomited. This should be done as soon as possible.
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