A client is admitted to the telemetry unit with an episode of substernal chest pain.

His diagnostic studies reveal an elevated ST segment on the electrocardiogram (ECG) and an elevated cardiac troponin level.

What would be an appropriate initial nursing goal?

Reduce anxiety and relieve pain.

Improve myocardial oxygenation and reduce cardiac workload.

Eliminate family stressors and provide a calm environment.

Start the client on a low-sodium diet and decrease fluid intake.

Answer and Explanation

The Correct Answer is B

Choice A rationale
While reducing anxiety and relieving pain are important aspects of care, they are not the primary goal for a client with an elevated ST segment on the ECG and an elevated cardiac troponin level. These findings indicate myocardial injury, which requires interventions to improve myocardial oxygenation and reduce cardiac workload.
Choice B rationale
The primary goal for a client with an elevated ST segment on the ECG and an elevated cardiac troponin level is to improve myocardial oxygenation and reduce cardiac workload. This can be achieved through medications, oxygen therapy, and bed rest.
Choice C rationale
Eliminating family stressors and providing a calm environment can contribute to reducing anxiety and promoting relaxation, but it is not the primary goal in this situation.
Choice D rationale
Starting the client on a low-sodium diet and decreasing fluid intake are interventions for managing heart failure, not for an acute myocardial injury.

Nursing Test Bank

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Correct Answer is ["B","D"]

Explanation

Choice A rationale
The need for Metoprolol (Lopresor) STAT does not necessarily indicate progression to septic shock. Metoprolol is a beta-blocker used to treat high blood pressure, heart failure, and angina. While it may be used in the management of sepsis to control heart rate, its use does not specifically indicate progression to septic shock.
Choice B rationale
The need for Norepinephrine to maintain a mean arterial pressure (MAP) greater than 65 mmHg despite fluid replacement is a strong indicator of septic shock. Norepinephrine is a vasopressor, a type of medication used to increase blood pressure. In septic shock, vasopressors are often required to maintain adequate blood pressure and organ perfusion despite aggressive fluid resuscitation.
Choice C rationale
A serum lactate level less than 2 mmol/L is generally not indicative of septic shock. Elevated lactate levels can indicate tissue hypoperfusion, a condition that may occur in septic shock. However, a level less than 2 mmol/L is typically considered within the normal range.
Choice D rationale
A blood pressure of 70/34 after the fluid bolus could indicate progression to septic shock. In septic shock, despite aggressive fluid resuscitation, blood pressure often remains dangerously low, which can lead to inadequate blood flow to the organs.

A. Sinus tachycardia. B. Ventricular tachycardia. C. Ventricular fibrillation. D. Atrial flutter.

Correct Answer is B

Explanation

Choice A rationale
Sinus tachycardia is a regular, rapid heart rate caused by rapid firing of the sinoatrial node. It is characterized by a heart rate of greater than 100 beats per minute, and P waves are present before each QRS complex. This does not match the description given.
Choice B rationale
Ventricular tachycardia is a fast, regular beating of the ventricles that may last for only a few seconds or for much longer. In this condition, the ventricular rate is often between 120 and 200 beats per minute, and P waves are not associated with the QRS complexes. This matches the description given.
Choice C rationale
Ventricular fibrillation is a severe condition in which the heart beats with rapid, erratic electrical impulses. This causes the ventricles to quiver uselessly instead of pumping blood. The description does not match this condition.
Choice D rationale
Atrial flutter is a condition that shares similarities with atrial fibrillation, both involve an irregular heartbeat. However, atrial flutter is more organized and less chaotic than atrial fibrillation, which can make it more manageable. The description does not match this condition.

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A client is admitted to the telemetry unit with an episode of substernal chest pain. His diagnostic studies reveal an elevated ST segment on the electrocardiogram (ECG) and an elevated cardiac troponin level. What would be an appropriate initial nursing goal?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","D"]

Explanation

Correct Answer is B

Explanation

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A client is admitted to the telemetry unit with an episode of substernal chest pain.

His diagnostic studies reveal an elevated ST segment on the electrocardiogram (ECG) and an elevated cardiac troponin level.

What would be an appropriate initial nursing goal?