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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Correct Answer is B

Explanation

Rationale

A. This statement is partially true as most sexually transmitted infections (STIs), including syphilis, are primarily transmitted through sexual intercourse. However, not all STIs are exclusively transmitted through sexual contact.

B. Syphilis is caused by the bacterium Treponema pallidum and can be transmitted through direct contact with a syphilitic sore (chancre) during vaginal, anal, or oral sex. If a person has syphilis and engages in unprotected sex with a partner who is not treated, they can potentially contract or transmit the infection again, leading to reinfection.

C. While contraceptives such as condoms provide protection against unintended pregnancy and some STIs, including syphilis, they do not offer complete protection against all STIs. Condoms are effective in reducing the risk of transmission of syphilis when used consistently and correctly, but they are not 100% protective.

D. Using safe sex practices, such as consistent and correct use of condoms, reduces the risk of acquiring or transmitting STIs, including syphilis. Safe sex practices also include mutual monogamy and regular testing for STIs, especially for those who have multiple sexual partners or engage in high-risk sexual behaviors.

A. Instruct the nurse to use water with 5% dextrose (DW). B. Send an unlicensed assistive personnel to gather equipment. C. Prompt the nurse to apply povidone to the site. D. Direct the nurse to attach the luer-lock tip to the irrigation port.

Correct Answer is D

Explanation

Rationale

A. Using water with 5% dextrose (DW) is appropriate for irrigating certain types of catheters, especially those that require a non-saline solution to maintain patency. However, the choice of irrigation solution should be based on the specific type of catheter and the facility's policies. It does not directly address the immediate issue of the luer-lock syringe.

B. Sending someone else to gather equipment may be necessary in some situations but does not address the current issue of the nurse preparing to irrigate with a luer-lock tipped syringe. This option delays addressing the immediate concern.

C. Applying povidone (such as povidone-iodine solution) to the site is a step in the preparation for aseptic technique but does not address the specific issue of the syringe type or the irrigation process itself.

D. Luer-lock syringes are commonly used for irrigation purposes because they securely attach to irrigation ports, preventing accidental disconnection during the procedure. Directing the nurse to attach the luer-lock syringe ensures that the irrigation can be performed safely and effectively.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having unprotected sex. Which response should the nurse provide?

Correct Answer is B

Explanation

The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse brought a luer-lock tipped syringe. Which action should the charge nurse take?

Correct Answer is D

Explanation

Exhibits The nurse starts the albuterol nebulizer as prescribed. Which should the nurse assess after the albuterol nebulizer treatment is complete? Select all that apply.

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath with activity. Which test should the nurse schedule the client for evaluation of the symptoms?

A client admitted with pneumonia and on bedrest has not had the strength to perform self care. Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?

An older adult client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) to assist in bathing, is becoming increasingly agitated and stating the UAP "wants to hurt me and tie me up." Which approach should the nurse use with the client?

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.