A client admitted to the coronary care unit with an inferior wall myocardial infarction is anxious, sweating, tachypneic, and reports midsternal chest discomfort and nausea.
Which nursing diagnosis is the priority?

Anxiety.

Acute pain.

Knowledge deficit.

Nausea and vomiting.

Answer and Explanation

The Correct Answer is B

This is because acute pain is the most urgent and life-threatening problem for a client with myocardial infarction.

Acute pain indicates ongoing ischemia and tissue damage, which can lead to complications such as heart failure, arrhythmias, or cardiogenic shock. Therefore, relieving pain is the priority nursing diagnosis.

Choice A. Anxiety is wrong because anxiety is not a specific symptom of myocardial infarction and anxiety is due to the discomfort that happens due to activation of the sympathetic pathway which is good for survival.

Choice C. Knowledge deficit is wrong because knowledge deficit is not an immediate problem for a client with myocardial infarction.

Knowledge deficit can be addressed after the acute phase of the condition is over and the client is stable.

Choice D. Nausea and vomiting are wrong because nausea and vomiting are common symptoms of myocardial infarction, but they are not as urgent and life-threatening as acute pain.

Nausea and vomiting can be treated with antiemetics and fluids, but they do not affect the outcome of the condition as much as pain does.

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Correct Answer is B

Explanation

Pulse oximetry works by measuring the amount of light that passes through your finger and reaches a sensor on the other side.

The amount of light that is absorbed by your blood depends on how much oxygen it carries. Nail polish can block or reflect some of the light, making it harder for the pulse oximeter to get an accurate reading of your oxygen level.

Choice A is wrong because the color of your nailbed is not relevant for pulse oximetry.

The pulse oximeter does not measure the color of your nailbed, but the amount of light that passes through it.

Choice C is wrong because the sensor does not react with the nail polish causing an allergic reaction.

The sensor is a non-invasive device that does not touch your skin or nail polish directly.

Choice D is wrong because the chemicals in the nail polish do not cause falsely decreased readings of your oxygen level.

The chemicals in the nail polish do not affect the amount of oxygen in your blood, but only the amount of light that reaches the sensor.

Normal ranges for pulse oximetry vary depending on your health condition and altitude, but generally they are between 95% and 100%. If your pulse oximetry reading is lower than 90%, you may have hypoxia, which means your tissues are not getting enough oxygen.

A. Notify the health care provider to report and anticipate new orders. B. Cover the client with an additional blanket & alert the UAP to recheck in two hours. C. Chart the temperature on the vital signs sheet and report to the new shift coming on. D. Assess the client’s temperature rectally and compare the results.

Correct Answer is A

Explanation

Notify the health care provider to report and anticipate new orders.

This is because an oral temperature of 100.8° F (38.2° C) indicates a fever, which could be a sign of infection or inflammation in an elderly client.

A fever of this magnitude could also cause dehydration, confusion, or seizures in older adults.

Therefore, the nurse should notify the health care provider as soon as possible to determine the cause and treatment of the fever.

Choice B is wrong because covering the client with an additional blanket could increase the body temperature and worsen the fever.

The UAP should not recheck the temperature in two hours, but rather monitor it more frequently and report any changes to the nurse.

Choice C is wrong because charting the temperature on the vital signs sheet and reporting to the new shift coming on is not enough to address the urgency of the situation.

The nurse has a responsibility to act on abnormal findings and communicate them to the health care provider.

Choice D is wrong because assessing the client’s temperature rectally and comparing the results is not necessary and could cause discomfort or injury to the client.

Rectal temperatures are usually higher than oral temperatures by about 0.5° F (0.3° C), so this would not change the interpretation of the fever.

The normal range for oral temperature in adults is 97.6° F to 99.6° F (36.4° C to 37.6° C).

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A client admitted to the coronary care unit with an inferior wall myocardial infarction is anxious, sweating, tachypneic, and reports midsternal chest discomfort and nausea. Which nursing diagnosis is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client asks a nurse, “Why do I have to remove my nail polish in order for my pulse oximetry to be monitored?” Which is the best response by the nurse?

Correct Answer is B

Explanation

A 75-year-old client has a baseline oral temperature of 96.8° F (36° C). Two hours later the client’s oral temperature is 100.8° F (38.2° C). Which action should a nurse take next?

Correct Answer is A

Explanation

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A client admitted to the coronary care unit with an inferior wall myocardial infarction is anxious, sweating, tachypneic, and reports midsternal chest discomfort and nausea.
Which nursing diagnosis is the priority?