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%

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["A","F"]

Explanation

Choice A rationale

Stabilizing the cervical spine is one of the first actions that should be taken during the primary survey of a trauma patient. This is to prevent any potential injury to the spinal cord, which could result in permanent paralysis.

Choice B rationale
Checking for a pulse is an important part of the primary survey, but it is not one of the first actions that should be taken. The first priority is to ensure that the airway is patent and the cervical spine is stabilized.

Choice C rationale
Requesting an x-ray is not one of the first actions that should be taken during the primary survey. The first priority is to assess the client’s airway, breathing, and circulation, and to stabilize the cervical spine.

Choice D rationale
Assessing the respiratory rate is an important part of the primary survey, but it is not one of the first actions that should be taken. The first priority is to ensure that the airway is patent and the cervical spine is stabilized.

Choice E rationale
Examining the abdomen is an important part of the secondary survey, which is conducted after the primary survey. The first priority during the primary survey is to assess the client’s airway, breathing, and circulation, and to stabilize the cervical spine.
Choice F rationale

Ensuring that the airway is patent is one of the first actions that should be taken during the primary survey. This is to ensure that the client is able to breathe effectively and receive adequate oxygenation.

A. Fluid volume deficit. B. Impaired bed mobility. C. Caregiver role strain. D. Bowel incontinence.

Correct Answer is A

Explanation

Choice A rationale
In a client with gastroenteritis experiencing fever, chills, anorexia, and diarrhea, fluid volume deficit is a major concern. Diarrhea and fever can both lead to significant fluid loss. If not addressed, fluid volume deficit can lead to serious complications such as hypovolemic shock.
Choice B rationale
While impaired bed mobility may be a concern due to the client’s history of stroke, it is not the highest priority in this situation. The immediate physiological needs related to the client’s gastroenteritis and potential fluid volume deficit should be addressed first.
Choice C rationale
Caregiver role strain may be a concern given that the client is dependent on care provided by the spouse. However, this psychosocial issue is not the highest priority when the client is experiencing acute physical symptoms that need immediate attention.
Choice D rationale
Bowel incontinence could be a concern for a client with gastroenteritis. However, the risk of fluid volume deficit due to diarrhea and fever is a more immediate concern.

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Naxlex Comprehensive Predictor Exams

The client is a 26-year-old female who fell from an apartment balcony. She was transported to the hospital via ambulance. The client enters the emergency room on a stretcher and is met in the trauma bay by the nurse. What two actions should the nurse take first during the primary survey?

Correct Answer is ["A","F"]

Explanation

Correct Answer is A

Explanation

The nurse is providing postoperative care for an adolescent who underwent a left leg amputation due to osteosarcoma. The adolescent reports experiencing phantom limb pain. Which non-pharmacological intervention should the nurse provide?

The nurse is educating a first-time pregnant woman about preeclampsia. Which symptoms are indicators of preeclampsia and should be reported to the healthcare provider? Select all that apply.

While conducting an admission assessment of a female client with bipolar disorder, the client suddenly starts to undress and throw her clothes around the room. What should be the nurse’s initial action?

Upon entering a patient’s room to administer an IV antibiotic at 0900, the nurse discovers that the patient is engaged in sexual activity with a visitor. What should be the nurse’s course of action?

A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client’s plan of care?