A client in the emergency department presents with chest pain, diaphoresis, and ST-segment elevation on ECG. Which condition should the nurse suspect?

Pulmonary embolism

Acute myocardial infarction

Pericarditis

Aortic dissection

Answer and Explanation

The Correct Answer is B

Choice A reason: Pulmonary embolism causes chest pain and diaphoresis but typically presents with tachycardia, dyspnea, and normal or non-specific ECG changes, not ST-segment elevation. The latter is specific to myocardial ischemia, making pulmonary embolism less likely. Embolism affects pulmonary circulation, not coronary arteries, which are implicated in the described ECG findings.

Choice B reason: Acute myocardial infarction presents with chest pain, diaphoresis, and ST-segment elevation on ECG, indicating acute coronary artery occlusion leading to myocardial ischemia. This is a life-threatening emergency requiring immediate intervention like percutaneous coronary intervention. The symptoms and ECG findings align with myocardial infarction, making it the most likely diagnosis.

Choice C reason: Pericarditis causes chest pain, often pleuritic, and may cause diaphoresis, but ECG typically shows diffuse ST-segment elevation, not localized as in myocardial infarction. Pericarditis is less likely to cause acute, severe ischemic symptoms. The specific ST elevation and symptoms point to coronary occlusion, not pericardial inflammation.

Choice D reason: Aortic dissection causes severe, tearing chest pain and may cause diaphoresis, but ECG is usually normal or shows non-specific changes, not ST-segment elevation. Dissection affects the aorta, not coronary arteries, making it less likely. The ECG findings and symptoms strongly suggest myocardial infarction over aortic dissection.

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 A

Explanation

Choice A reason: Chest tube discomfort can significantly limit deep breathing and ambulation, increasing atelectasis risk. Administering pain medication reduces discomfort, enabling the patient to perform deep breathing exercises and ambulate, which promote lung expansion and prevent complications like pneumonia. Pain control directly enhances compliance with these critical activities.

Choice B reason: Educating the patient about lung expansion’s importance may improve understanding but does not address the physical barrier of pain. Pain limits the ability to perform deep breathing and ambulation, making education alone insufficient. Pain management is needed first to enable compliance with these respiratory and mobility interventions.

Choice C reason: Arranging rest periods supports patient recovery but does not directly address pain, the primary barrier to deep breathing and ambulation. While rest is important, it does not facilitate the active participation required for lung expansion or mobility, which are critical to prevent respiratory complications in chest tube patients.

Choice D reason: Teaching incentive spirometer use promotes lung expansion but is ineffective if pain prevents deep breathing. The chest tube’s discomfort limits the patient’s ability to use the device effectively. Pain management must precede teaching to ensure the patient can perform the necessary respiratory exercises without discomfort hindering compliance.

A. A female who is pregnant at 20 weeks of gestation, has multiple cuts and abrasions, and is walking around B. A client who has a simple fracture of the femur, multiple scratches on both legs, and is crying hysterically C. A client who has severe head injuries, respiratory rate 8/min, and is unresponsive D. A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound

Correct Answer is D

Explanation

Choice A reason: A pregnant female with cuts and abrasions who is ambulatory has stable vital signs in the triage context. Minor injuries like cuts do not compromise airway, breathing, or circulation immediately. In mass casualty triage, she is a lower priority (green tag) compared to clients with life-threatening conditions like chest trauma.

Choice B reason: A simple femur fracture with scratches and emotional distress indicates pain and potential blood loss but not immediate life-threatening issues. Crying hysterically suggests intact neurological and airway status. In triage, this client is stable (yellow tag) compared to those with airway or breathing compromise, making them a lower priority.

Choice C reason: Severe head injuries with a respiratory rate of 8/min and unresponsiveness indicate neurological and respiratory compromise. This is critical, warranting a red tag, but the client with a chest wound and hissing sound suggests a tension pneumothorax, which can cause immediate cardiopulmonary collapse, taking precedence in triage due to rapid lethality.

Choice D reason: A chest wound with an audible hissing sound indicates a sucking chest wound or tension pneumothorax, a life-threatening emergency. Air entering the pleural space collapses the lung, impairing breathing and circulation. In mass casualty triage, this client requires immediate intervention (red tag) to seal the wound and restore respiratory function, making them the priority.

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 client in the emergency department presents with chest pain, diaphoresis, and ST-segment elevation on ECG. Which condition should the nurse suspect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is unable to take a deep breath and does not want to get out of bed due to chest tube discomfort. To increase the client's compliance with ambulation and deep breathing, the nurse should:

Correct Answer is A

Explanation

A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the priority for care?

Correct Answer is D

Explanation

A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first?

A nurse is caring for a client with septic shock. The client’s blood pressure is 80/50 mm Hg, and lactate levels are elevated. Which intervention is the nurse’s priority?

A client with chronic obstructive pulmonary disease (COPD) is admitted with acute exacerbation and respiratory distress. Which finding requires immediate intervention by the nurse?

A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency?

A client with cirrhosis is admitted with hematemesis and tachycardia. The nurse suspects variceal bleeding. Which action should the nurse take first?

A client who has broken his femur presents to the emergency department with the following signs and symptoms: cool, moist skin, increased heart rate, and falling blood pressure. The nurse suspects the client is experiencing:

A nurse is caring for a client with acute pancreatitis in the ICU. The client develops sudden dyspnea and oxygen saturation of 85%. Which intervention should the nurse prioritize?