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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Correct Answer is C

Explanation

Choice A rationale
Vegetarian lasagna with cheese and spinach, a tossed green salad with ranch dressing, and fresh fruit is a balanced meal. However, it may not be the best choice for a patient with type 2 diabetes due to the high carbohydrate content in the lasagna and the dressing.
Choice B rationale
Fried chicken breast, mashed potatoes, green beans, sliced tomatoes, and fresh apple pie is not the best choice for a patient with type 2 diabetes. Fried foods and mashed potatoes are high in carbohydrates and fats, which can raise blood sugar levels.
Choice C rationale
Grilled fish with whole-grain brown rice, steamed broccoli, and a pear poached in red wine is a good choice for a patient with type 2 diabetes. This meal is balanced with lean protein, whole grains, and vegetables, which can help control blood sugar levels.

Choice D rationale
Lean hamburger with cheese, tomato, and lettuce on a whole-wheat bun, and angel food cake is not the best choice for a patient with type 2 diabetes. Although the hamburger is lean, the whole-wheat bun and angel food cake are high in carbohydrates, which can raise blood sugar levels.

A. Administer oxygen via a face mask. B. Apply an internal fetal heart monitor. C. Use a vibroacoustic stimulator. D. Notify the healthcare provider.

Correct Answer is A

Explanation

Choice A rationale
Administering oxygen via a face mask is the first intervention the nurse should do. This is because the decrease in fetal heart rate after the last four contractions indicates possible fetal distress, which can be caused by insufficient oxygen. Administering oxygen to the mother can increase the amount of oxygen available to the fetus, potentially alleviating the distress.
Choice B rationale
Applying an internal fetal heart monitor can provide more accurate and continuous data about the fetal heart rate and contractions. However, this is usually not the first intervention because it is invasive and can only be done if the cervix is sufficiently dilated and the membranes have ruptured.
Choice C rationale
Using a vibroacoustic stimulator is a method used to wake a sleeping baby in the womb during a non-stress test. It is not typically used in response to signs of fetal distress during labor.

Choice D rationale
Notifying the healthcare provider is important when there are signs of fetal distress. However, the nurse has interventions, such as administering oxygen, that they can and should do immediately while the healthcare provider is being notified.

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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