A client is admitted to the telemetry unit due to an episode of substernal chest pain.
Diagnostic tests reveal an elevated ST segment on the electrocardiogram (ECG) and an increased cardiac troponin level.
What would be an appropriate initial nursing intervention?
Reduce anxiety and alleviate pain.
Enhance myocardial oxygenation and decrease cardiac workload.
Remove family stressors and provide a tranquil environment.
Initiate a low-sodium diet and limit fluid intake.
The Correct Answer is B
Choice A rationale
While reducing anxiety and alleviating pain are important, they are not the most appropriate initial nursing intervention for a client with substernal chest pain, elevated ST segment on the ECG, and increased cardiac troponin level.
Choice B rationale
Enhancing myocardial oxygenation and decreasing cardiac workload are crucial initial nursing interventions for a client presenting with these symptoms. These actions can help prevent further damage to the heart muscle.
Choice C rationale
Removing family stressors and providing a tranquil environment, while beneficial, are not the most appropriate initial nursing interventions for a client with these symptoms.
Choice D rationale
Initiating a low-sodium diet and limiting fluid intake are important for managing heart failure, but they are not the most appropriate initial nursing interventions for a client with these symptoms.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Iron supplements for anemia do not typically interact with warfarin (Coumadin). Iron is a mineral that is essential for the production of red blood cells, and supplements are often prescribed to patients with anemia to increase their iron levels. While it’s important for healthcare providers to be aware of all medications and supplements a patient is taking, iron supplements are not known to diminish the effects of warfarin.
Choice B rationale
Furosemide (Lasix) is a diuretic medication used to treat fluid retention. It works by causing the kidneys to get rid of unneeded water and salt from the body into the urine. While furosemide can interact with other medications, it is not known to diminish the effects of warfarin.
Choice C rationale
Simvastatin (Zocor) is a medication used to control cholesterol levels. It works by slowing the production of cholesterol in the body to decrease the amount of cholesterol that may build up on the walls of the arteries and block blood flow to the heart, brain, and other parts of the body. Simvastatin does not typically interact with warfarin to diminish its effects.
Choice D rationale
Yaz (drospirenone/estradiol) is an oral contraceptive that contains estrogen. Estrogen can potentially increase the effects of warfarin, leading to an increased risk of bleeding. Therefore, if a patient taking warfarin also takes Yaz, it could potentially diminish the effects of warfarin, making it less effective. This is why it’s important for healthcare providers to be aware of all medications a patient is taking, including oral contraceptives.
Correct Answer is C
Explanation
Choice A rationale
While assessing the gag reflex is important in certain situations, such as after surgery involving anesthesia, it is not typically a crucial assessment following Percutaneous Transluminal Angioplasty (PTA) of the lower extremity.
Choice B rationale
Checking for dye allergies is important before a procedure that uses contrast dye. However, it is not a crucial post-procedure assessment.
Choice C rationale
Monitoring of pedal pulses is crucial following PTA of the lower extremity. This is because the procedure involves the arteries in the legs, and monitoring pedal pulses can help assess blood flow to the area and detect potential complications such as occlusion or clot formation.
Choice D rationale
While the Ankle-Brachial Index can be used to diagnose Peripheral Arterial Disease (PAD), it is not typically a crucial assessment immediately following PTA3.
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