A client is admitted to the emergency department 5 days after an acute coronary syndrome (ACS) troubled by severe fatigue, muscle weakness, and shortness of breath. The client's electrocardiogram (ECG) Indicates sinus tachycardia and the laboratory findings indicate an elevated serum brain natriuretic peptide (BNP) level. Which action is most important for the nurse to implement?

Insert an indwelling urinary catheter.

Obtain blood for serum cardiac enzymes.

Provide emotional support.

Auscultate lung fields for fine rales.

Answer and Explanation

The Correct Answer is D

A.   Inserting an indwelling urinary catheter may be considered if the client is unable to urinate or if precise measurement of urine output is crucial for assessing fluid status. However, in this context, the immediate concern is more likely related to the client's cardiovascular status and respiratory symptoms rather than urinary output.
B.   Serum cardiac enzymes (such as troponin, CK-MB) are important for diagnosing acute myocardial infarction or myocardial injury. While this is relevant for assessing cardiac damage, the elevated BNP level and current symptoms suggest that heart failure or fluid overload might be more pressing concerns.

C.   Emotional support is important for any patient, especially those dealing with significant health issues. However, in this situation, the priority should be on addressing the immediate physiological concerns related to the client's symptoms and laboratory findings. Emotional support can be provided alongside other clinical interventions but should not be the primary action in this acute setting.
D.   Fine rales (or crackles) in the lung fields are often associated with pulmonary congestion or fluid
overload, which are common in heart failure. Given the elevated BNP level and the client’s symptoms of
shortness of breath and fatigue, assessing the lung fields for rales is crucial.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. While assessing peripheral pulses is important, it's not the priority in this situation. The primary concern is the rectal bleeding.
B. These exercises are important to prevent postoperative complications like pneumonia, but they are not the immediate priority when a patient is experiencing rectal bleeding.
C. Assessing the abdomen will help determine the severity of the bleeding, identify any signs of abdominal distention or tenderness, and provide crucial information for further interventions.
D. Monitoring fluid intake and output is important for any patient, but it's not the initial priority when a patient is actively bleeding.

A. Obtain current vital signs. B. Measure abdominal girth. C. Observe for flushing D. Auscultate breath sounds.

Correct Answer is A

Explanation

A. Vital signs are critical for assessing the client’s current hemodynamic status. Coffee-ground emesis can indicate gastrointestinal bleeding, which might lead to complications like hypovolemia or shock.

Vital signs can provide essential information about the client’s condition and help determine the urgency of intervention. Checking vital signs is a priority in assessing the severity of the situation and guiding further actions.
B. Measuring abdominal girth is useful in assessing for abdominal distention or fluid accumulation, which can be relevant in some gastrointestinal conditions. However, in the immediate context of coffee- ground emesis, the most urgent concern is evaluating the client's hemodynamic stability rather than focusing on abdominal girth.
C. Flushing of the skin might be relevant in certain contexts (e.g., reactions to medications or infections), but it is not directly related to the immediate concern of gastrointestinal bleeding and the client’s hemodynamic status. It is less critical compared to assessing vital signs in this situation.
D. While auscultating breath sounds is important for evaluating respiratory status and detecting any pulmonary complications, it is not the immediate priority in the context of coffee-ground emesis. The primary concern should be assessing for signs of hemodynamic instability that may result from gastrointestinal bleeding.

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Naxlex Comprehensive Predictor Exams

An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which Intervention should the nurse do first?

Correct Answer is C

Explanation

After being transferred from the emergency department to a medical unit, a client vomits into an emesis basin. The nurse observes the emesis as seen in the picture. Which assessment should the nurse complete first?

Correct Answer is A

Explanation

Exhibits The nurse provides education about seizures to the client and asks the client to explain what he understands about his condition. For each statement click to specify if the client demonstrates an understanding or no understanding. Each row must have one option selected.

The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?

A client with coronary artery disease is hospitalized with unstable angina. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?

The nurse has determined that a client with trigeminal neuralgia has the nursing problem, "Imbalanced nutrition, less than body requirements." Which cause is most likely contributing to the problem?

The nurse observes a client who begins to exhibit continuous jerking movements, is unable to speak, and is incontinent of urine during the event. Which action is most important for the nurse to take?

The nurse is evaluating a client's symptoms, and formulates the nursing problem, "High risk for injury due to potential urinary tract infection." Which symptoms indicate the need for this nursing problem?

When learning to use an insulin pen, a client with diabetes dials 28 units of regular insulin instead of 24 units, the prescribed dose. Which action should the nurse take?