The nurse is performing an admission assessment of a client complaining of chest pain. Which question(s) should the nurse ask in the assessment regarding the chief complaint? (SELECT ALL THAT APPLY)

"What were you doing when the pain started?"

"How long has the pain lasted?"

"How would you describe the pain?"

"How has the pain affected your relationship with your spouse?"

"Can you rate the pain on a 0-10 scale with 10 being the worst?"

Answer and Explanation

Correct Answer : A,B,C,E

A. "What were you doing when the pain started?" This question helps identify potential triggers or activities that may have precipitated the chest pain, which is crucial for understanding the context of the pain.

B. "How long has the pain lasted?" Knowing the duration of the pain is vital in assessing the urgency of the situation and determining whether it may be related to a serious condition like angina or myocardial infarction.

C. "How would you describe the pain?" This question allows the client to characterize the pain (e.g., sharp, dull, squeezing), which can provide insights into the potential causes and the nature of the chest pain.

D. "How has the pain affected your relationship with your spouse?" While this question might provide some psychosocial context, it is less directly related to the immediate assessment of the chest pain itself and can be considered secondary.

E. "Can you rate the pain on a 0-10 scale with 10 being the worst?" Pain rating is essential in assessing the severity of the pain, which can help guide treatment and interventions.

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

Explanation

A) Allow for rest periods between activities throughout the day: This intervention is essential for a client with activity intolerance. Incorporating rest periods helps to manage fatigue and allows for recovery, particularly when hypoxemia is a concern due to sickle cell anemia.
B) Provide supplemental oxygen when the pulse oximetry falls below 96%: Administering supplemental oxygen when oxygen saturation levels drop below 96% is crucial for preventing further hypoxemia and ensuring adequate tissue perfusion, thus addressing the client's activity intolerance.

C) Perform serial neurologic assessments to maintain safety and prevent injury: Regular neurologic assessments are vital, especially in clients with sickle cell anemia, who are at risk for complications like stroke. This intervention helps monitor for changes in neurological status, ensuring prompt action if needed.

D) Assess ability to perform activities of daily living (ADLs): Evaluating the client’s ability to perform ADLs provides valuable information on their functional status and helps tailor interventions to promote independence while considering their limitations due to hypoxemia.

E) Monitor blood pressure, pulse, and respirations after activity: This monitoring is important to evaluate the client’s response to activity and to detect any changes that could indicate distress or worsening hypoxemia. This information helps guide further interventions and ensures the client’s safety.

A. Blood urea nitrogen (BUN) 20 mg/d B. Creatinine 2.6 mg/dl C. Hemoglobin 12.8 g/dl D. Potassium 3.8 mEq/L

Correct Answer is B

Explanation

A) Blood urea nitrogen (BUN) 20 mg/dL: While this BUN level is slightly elevated, it is not as concerning as the creatinine level. Elevated BUN can indicate dehydration or other issues but does not necessarily signal acute kidney injury.

B) Creatinine 2.6 mg/dL: This result is the most concerning because it indicates impaired kidney function. Normal creatinine levels are typically between 0.6 and 1.2 mg/dL. An elevated creatinine level suggests that the kidneys are not filtering waste effectively, which is a significant concern for a client with long-standing hypertension.

C) Hemoglobin 12.8 g/dL: This hemoglobin level is within the normal range for adults and does not present an immediate concern.

D) Potassium 3.8 mEq/L: This potassium level is also within the normal range (3.5 to 5.0 mEq/L) and does not raise any alarms in terms of electrolyte imbalances.

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The nurse is performing an admission assessment of a client complaining of chest pain. Which question(s) should the nurse ask in the assessment regarding the chief complaint? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client problem of Activity Intolerance related to hypoxemia from sickling RBCs has been made for a client with sickle cell anemia. Which intervention should the nurse include in the plan of care? (SELECT ALL THAT APPLY)

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

Explanation

The nurse is reviewing the laboratory test results of a client with long standing hypertension. Which result would be of most concern to the nurse?

Correct Answer is B

Explanation

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