The nurse is providing care for a client admitted to rule out a myocardial infarction who is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first?
Obtain a STAT electrocardiogram
Have the client sit down immediately
Assess the client's vital signs
Administer sublingual nitroglycerin
The Correct Answer is B
A. Obtaining an ECG is important but not the first action. The priority is to stop activity, as exertion can worsen myocardial oxygen demand.
B. Having the client sit down immediately is correct. Stopping activity reduces cardiac workload and oxygen demand, preventing further ischemia or infarction.
C. Assessing vital signs is important but should follow stopping activity. Chest pain requires immediate action to reduce cardiac strain.
D. Administering sublingual nitroglycerin is appropriate but should be done after ensuring the client is seated. This prevents hypotension and syncope from occurring while standing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Weight gain is more commonly associated with right-sided heart failure due to fluid retention and peripheral edema, not left-sided heart failure.
B. Shortness of breath (dyspnea) is correct. Left-sided heart failure causes pulmonary congestion, leading to dyspnea, orthopnea, and pulmonary edema as blood backs up into the lungs.
C. Pulmonary embolism is not a direct manifestation of left-sided heart failure. While heart failure increases the risk of clot formation, a pulmonary embolism is a separate condition.
D. Anorexia is more common in right-sided heart failure, as systemic venous congestion can lead to gastrointestinal edema and poor appetite.
Correct Answer is D
Explanation
A. Use of accessory muscles during inspiration is common in COPD as clients work harder to breathe. While this indicates respiratory distress, it is not necessarily an immediate emergency.
B. Large amounts of thick white sputum can indicate mucus production, which is common in COPD. If the sputum were yellow or green, it could suggest infection, requiring further assessment.
C. A barrel chest and clubbing are chronic changes in COPD due to prolonged air trapping and hypoxia. These findings do not require immediate intervention.
D. Oxygen flowmeter set on 8 LPM is correct. High-flow oxygen can suppress the hypoxic drive in COPD clients, leading to respiratory depression. The nurse should immediately lower the oxygen to a safer level (typically 1-3 LPM) and monitor the client’s respiratory status.
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