A 40-year-old patient is admitted with sharp, pleuritic chest pain and dyspnea. The nurse observes jugular venous distension and muffled heart sounds on examination. What is the most appropriate initial nursing action for this patient?

Encouraging the patient to take deep breaths and cough

Administering oxygen to maintain adequate oxygenation

Positioning the patient flat in bed to decrease discomfort

Providing the patient with a warm compress to relieve chest pain

Positive Tinel's sign

Answer and Explanation

The Correct Answer is B

A.   Encouraging the patient to take deep breaths and cough would not address the underlying cause of the symptoms, which may indicate a more serious condition.
B.   Administering oxygen to maintain adequate oxygenation is the most appropriate initial action, as the patient’s symptoms suggest a potentially life-threatening condition like a cardiac tamponade or pulmonary embolism.
C.   Positioning the patient flat in bed is not recommended, as it may exacerbate breathing difficulties and
the patient’s distress.
D.   A warm compress is unlikely to be beneficial in this acute situation and could delay appropriate intervention.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["B","E"]

Explanation

A. Loss of urine during laughing or sneezing is typically associated with stress incontinence, not overflow or functional incontinence.
B. Constant dribbling of urine despite frequent urination is a hallmark of overflow incontinence, often caused by an underactive bladder or obstruction.
C. Frequent urination at night with a strong urge is more characteristic of urge incontinence.
D. Sudden and intense urge to urinate followed by loss of urine is also indicative of urge incontinence.
E. Inability to access the toilet in time due to physical limitations, such as arthritis, is common in functional incontinence, where the person is unable to reach the bathroom in time despite normal bladder function.

A. "It is important to follow up with a GI specialist for recommended surveillance for Barrett's esophagus". B. "It is important to watch for manifestations of pancreatic cancer." C. "Follow-up with an endocrinologist as your risks for diabetes increases." D. "You will need to monitor for manifestations of liver issues."

Correct Answer is A

Explanation

A. Barrett's esophagus is a complication of GERD and is associated with an increased risk of esophageal cancer. It is essential for the patient to follow up with a GI specialist for surveillance.
B. Pancreatic cancer is not directly related to GERD, so the nurse should not suggest watching for symptoms of this condition.
C. Diabetes risk is not directly increased by GERD. Therefore, follow-up with an endocrinologist is unnecessary unless the patient has other risk factors for diabetes.
D. Liver issues are not typically associated with GERD, so monitoring for liver problems would not be a primary concern in this case.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A 40-year-old patient is admitted with sharp, pleuritic chest pain and dyspnea. The nurse observes jugular venous distension and muffled heart sounds on examination. What is the most appropriate initial nursing action for this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 68-year-old male patient is presenting with urinary incontinence. Which characteristics are commonly associated with overflow incontinence and functional incontinence? (Select All that Apply.)

Correct Answer is ["B","E"]

Explanation

A nurse is providing teaching to a client who has long-term symptoms of GERD (gastroesophageal reflux disease). Which of the following statements should the nurse include in the educational materials?

Correct Answer is A

Explanation

A nurse is planning care for a client who has multiple sclerosis and is receiving methylprednisolone. Which of the following adverse effects should the nurse anticipate? (Select all that apply.)

A patient with COPD is receiving oxygen therapy. Which considerations are important to ensure safe and effective oxygen administration for this patient? (Select All that Apply.)

A nurse is preparing to administer an enteral feeding to a patient with a gastrostomy tube. Before starting the feeding, which of the following actions should the nurse take to ensure patient safety?

A 45-year-old patient presents with epigastric pain, nausea, and bloating. The physician suspects gastritis. Which diagnostic test would be most appropriate to confirm the presence of Helicobacter pylori infection as a cause of gastritis?

A nurse is preparing to administer oxygen therapy to a patient who has just undergone abdominal surgery. Which of the following interventions is most important to ensure proper oxygenation?

A patient is diagnosed with acute gastritis. Which of the following interventions and assessments should the nurse consider to effectively manage this condition? (Select All that Apply.)

A nurse is caring for a client who continues to have issues with GERD (gastroesophageal reflux disease). Which of the following statements provides the best preventative health care education for this client?