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.

Nursing Test Bank

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Correct Answer is C

Explanation

Rationale

A. A living will often includes directives regarding life-sustaining treatments, including intubation. If the living will explicitly states a preference against intubation, the nurse should ensure this information is known to the healthcare team. However, a living will does not automatically imply a DNR status unless specifically stated.

B. When a living will is presented, and decisions need to be made regarding life-sustaining treatments like intubation, it is appropriate to facilitate a family meeting. In this meeting, the healthcare team, including palliative care specialists if available, can discuss the client's wishes as outlined in the living will. The goal is to ensure everyone understands the client's preferences and to make informed decisions about the course of treatment.

C. The nurse should notify the attending healthcare provider about the existence of the client's living will and its directives regarding medical interventions such as intubation. The healthcare provider needs to be aware of the client's wishes to guide the decision-making process and ensure appropriate care is provided according to the client's preferences.

D. It is crucial to ensure that the living will, once verified and certified as authentic, is placed in the client's medical record. This document serves as a legal and ethical guide for healthcare decisions, especially during critical situations like an exacerbation requiring intubation.

A. Lung biopsy. B. Antibody testing. C. Sweat test. D. Spirometry.

Correct Answer is D

Explanation

Rationale

A. A. lung biopsy involves obtaining a tissue sample from the lung for microscopic examination. It is typically performed to diagnose conditions such as lung cancer or to investigate unusual findings seen on imaging studies. However, for a client with COPD experiencing increased shortness of breath, a lung biopsy is not typically indicated as a first-line investigation. It is more invasive and usually reserved for specific diagnostic purposes other than routine evaluation of COPD symptoms.

B. Antibody testing is used to detect antibodies specific to certain infections or autoimmune conditions. It is not typically used in the routine evaluation of COPD symptoms unless there is suspicion of a specific autoimmune or infectious cause contributing to exacerbations, which is less common in COPD compared to other conditions.

C. A. sweat test is used to diagnose cystic fibrosis (CF), a genetic disorder that affects the lungs and digestive system. It measures the amount of chloride in sweat, which is elevated in individuals with CF. Since COPD and CF are distinct conditions with different underlying causes and diagnostic criteria, a sweat test is not appropriate for evaluating COPD symptoms.

D. Spirometry is the most appropriate test to schedule for evaluating a client with COPD who reports increased shortness of breath with activity. Spirometry measures lung function by assessing how much and how quickly a person can move air into and out of their lungs. It provides valuable information about the severity of airflow limitation, which is characteristic of COPD.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

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?

Correct Answer is D

Explanation

Exhibits The nurse is reviewing the client's chart. For each finding, click to indicate whether findings suggest that the client's condition has improved or put the client at risk for hypovolemia. Each column must have at least one selection.

A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPS. Which intervention should the home health nurse implement to ensure adequate care for all clients?

The nurse is preparing a client for an outpatient thoracentesis. Which statement made by the client should the nurse recognize as needing additional education?

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.)

The nurse assesses the client after the dose of albuterol and documents the findings in the chart. Exhibits Which action(s) should the nurse plan for the rest of the shift? Select all that apply.

When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

A client with metastatic cancer who was taking hydromorphone PO at home is now receiving the medication IV while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete?