A client with coronary artery disease (CAD) is admitted to the medical unit for testing. The client describes having had frequent episodes of angina over the last few days prior to admission. The client is now experiencing shortness of breath, nausea, and chest pressure. After obtaining the client's vital signs, which action should the nurse take next?

Verify troponin level assessments are scheduled every 3 to 6 hours for a series of three.

Initiate dim lighting, lower alarm volumes, and control traffic in and out of the room area.

Count and record the number of premature ventricular contractions per minute.

Apply oxygen via nasal cannula and titrate to keep oxygen saturation above 93%.

Answer and Explanation

The Correct Answer is D

Rationale

A. Troponin levels are cardiac biomarkers that are elevated in the blood when there is damage to the heart muscle, such as during a myocardial infarction (heart attack). Verifying the schedule for troponin assessments is important to monitor for myocardial damage and to guide treatment decisions.

B. This action is aimed at creating a quiet and calm environment for the client, which can help reduce anxiety and minimize stimuli that might exacerbate symptoms. Creating a conducive environment is beneficial for the client's comfort and well-being but should not delay urgent interventions required for acute symptoms.

C. PVCs are abnormal heartbeats that can occur in individuals with CAD and may indicate increased cardiac irritability or instability. While monitoring PVCs is important for assessing cardiac rhythm and potential complications, it is not the immediate priority over addressing acute symptoms such as shortness of breath, nausea, and chest pressure.

D. Oxygen therapy is essential in the management of a client with suspected ACS to improve oxygenation and reduce cardiac workload. Maintaining oxygen saturation above 93% helps ensure adequate tissue oxygenation, especially during episodes of chest discomfort and potential myocardial ischemia.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale

A. Osteoarthritis is characterized by the gradual destruction of joint cartilage. Cartilage serves as a cushion between the bones in a joint, and its deterioration leads to pain, stiffness, and reduced joint function. As the cartilage wears away, bones may rub directly against each other, causing further pain and damage.

B. Osteoarthritis is primarily a degenerative condition rather than an inflammatory one. While mild inflammation can occur in OA, it is not as prominent as in autoimmune conditions like rheumatoid arthritis. In OA, inflammation is secondary to cartilage damage rather than a primary driver of the disease process.

C. Loss of bone mineral density is more characteristic of osteoporosis, a condition where bones become weak and brittle. Osteoporosis involves a decrease in bone mass throughout the skeleton, whereas osteoarthritis specifically targets the joints and affects cartilage rather than bone density.

D. An infectious process in the synovial fluid could indicate septic arthritis, which is characterized by infection in the joint space. This is typically associated with acute symptoms such as severe joint pain, swelling, warmth, and fever.

A. Monitor blood glucose level. B. Maintain strict intake and output. C. Assess warmth of extremities. D. Keep head of bed raised 45 degrees.

Correct Answer is B

Explanation

Rationale

A. Monitoring blood glucose levels is important, especially in critically ill patients, as hyperglycemia can worsen outcomes in septic shock. However, it is not the most critical intervention in the immediate management of septic shock.

B. Monitoring intake and output (I/O) is essential for assessing fluid balance, which is crucial in managing septic shock. Maintaining a strict I/O helps in determining fluid resuscitation needs and evaluating response to treatment. This intervention is important but may not be the most critical initially.

C. Assessing warmth of extremities is important as it helps in evaluating peripheral perfusion, which can be compromised in septic shock. Cold extremities can indicate poor tissue perfusion and may prompt the need for interventions such as fluid resuscitation.

D. Keeping the head of the bed elevated to 45 degrees is a specific intervention aimed at improving oxygenation and respiratory function, particularly in patients who may be mechanically ventilated or at risk of respiratory compromise. While this is an important intervention, it is not directly related to managing septic shock itself.

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Naxlex Comprehensive Predictor Exams

An older client with osteoarthritis reports increasing pain and stiffness in the right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of the symptoms?

Correct Answer is A

Explanation

The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

Correct Answer is B

Explanation

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Exhibits The nurse reviews the healthcare providers (HCP) prescription for clonazepam and gives the medication as prescribed. Which nursing intervention(s) is/are appropriate for the client starting clonazepam? Select all that apply.

A client receives a prescription for 1 L of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Exhibits Based on the assessment data, the nurse recognizes the need to intervene immediately. Select the 5 priority interventions that the nurse should initiate based on the most recent assessment.

Exhibits The nurse discusses the keep to balance energy intake and output to maintain weight Click to indicate whether the following actions would be effective or ineffective for this client to achieve energy balance. Each row must have one option selected.