A client diagnosed with angina pectoris appears to be very anxious and states, "So I had a heart attack, right?" Which response should the nurse make to the client?

"Yes, that's why you are hospitalized."

"Yes, but it will never happen again."

"No, but it is necessary to monitor, control, and eliminate your chest pain."

"No, it is normal to feel chest pain."

Answer and Explanation

The Correct Answer is C

Choice A reason: Telling the client that they are hospitalized due to a heart attack when it is not the case can cause unnecessary anxiety and fear. It is important to provide accurate information and reassurance.

Choice B reason: Stating that it will never happen again is unrealistic and provides false reassurance. It is important to focus on managing the client's condition and reducing the risk of future episodes.

Choice C reason: Explaining that the client did not have a heart attack but emphasizing the importance of monitoring and managing chest pain provides accurate information and reassurance. It helps reduce the client's anxiety and provides a clear plan of action.

Choice D reason: Saying it is normal to feel chest pain without further explanation can cause confusion and anxiety. It is important to clarify that chest pain needs to be monitored and managed to prevent complications.

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Correct Answer is A

Explanation

Choice A reason: Hyperkalemia is a common finding in the oliguric phase of acute kidney injury due to reduced excretion of potassium by the kidneys. This electrolyte imbalance can have serious cardiac effects and should be expected and monitored in these patients.

Choice B reason: An increased glomerular filtration rate (GFR) would not be expected in the oliguric phase of acute kidney injury. Typically, GFR is decreased due to reduced kidney function during this phase.

Choice C reason: Decreased creatinine levels are not expected in acute kidney injury. Creatinine levels usually increase as kidney function declines and the body cannot adequately filter waste.

Choice D reason: Hypovolemia is not typically expected in the oliguric phase of acute kidney injury, as oliguria (reduced urine output) often indicates fluid retention rather than fluid loss.

A. Prepare for the administration of IV fluids B. Administer a bolus of IV fluids C. Administer Atenolol stat D. Administer Nitroglycerin

Correct Answer is B

Explanation

Choice A reason: Preparing for the administration of IV fluids is important but not as immediate as administering a bolus of IV fluids. Immediate fluid resuscitation is crucial for addressing low blood pressure and improving the patient's hemodynamic status.

Choice B reason: Administering a bolus of IV fluids is the priority nursing action for a patient with symptomatic hypotension. Rapid fluid administration helps to increase blood volume and improve blood pressure, which is essential for stabilizing the patient.

Choice C reason: Administering Atenolol, a beta-blocker, is not appropriate for a patient with hypotension. Beta-blockers can further lower blood pressure and are contraindicated in this situation.

Choice D reason: Administering Nitroglycerin is not suitable for a patient with hypotension. Nitroglycerin can cause vasodilation and further decrease blood pressure, which would worsen the patient's condition.

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A client diagnosed with angina pectoris appears to be very anxious and states, "So I had a heart attack, right?" Which response should the nurse make to the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the med-surgical ICU is assessing a client in the oliguric phase of acute kidney injury. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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