A nurse in an emergency department is caring for a client.
Select the 4 actions the nurse should take.
Administer oxygen at 2 L/min via nasal cannula.
Obtain arterial blood gases.
Prepare to administer antiplatelet therapy.
Perform a 12-lead ECG.
Prepare the client for a cardiac catheterization.
Request a prescription for a sputum culture.
Correct Answer : A,C,D,E
A. Administer oxygen at 2 L/min via nasal cannula is correct because the client is showing signs of acute coronary syndrome (ACS) with worsening chest pain, tachycardia, tachypnea, and oxygen saturation dropping to 89%. Oxygen therapy helps improve myocardial oxygenation and reduces ischemia in hypoxic or unstable clients.
B. Obtain arterial blood gases is not the priority action. While ABGs can provide information about oxygenation and acid-base status, the immediate priorities in suspected myocardial infarction are restoring coronary perfusion, improving oxygen delivery, and obtaining diagnostic confirmation via ECG and labs already trending positive for myocardial injury.
C. Prepare to administer antiplatelet therapy is correct. The rising troponin levels and worsening symptoms indicate acute myocardial infarction. Antiplatelet therapy (such as aspirin or other platelet inhibitors) is essential to prevent further clot formation and limit myocardial damage.
D. Perform a 12-lead ECG is correct. A 12-lead ECG is a key diagnostic tool for confirming myocardial infarction and identifying ST elevation or ischemic changes. It should be obtained immediately in a client with chest pain and elevated cardiac markers.
E. Prepare the client for a cardiac catheterization is correct. Cardiac catheterization is indicated for definitive diagnosis and potential intervention (e.g., PCI/stent placement) in acute myocardial infarction, especially with rising troponins and worsening clinical status.
F. Request a prescription for a sputum culture is incorrect because there is no indication of respiratory infection. The client’s symptoms are consistent with acute coronary syndrome, not pneumonia or infectious respiratory disease, so this intervention is not relevant or priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Breastfeeding should not be strictly time-limited. Newborns need to feed based on their own hunger and satiety cues, and feeding duration varies widely (often 10–20+ minutes per breast). Limiting time can interfere with adequate intake of both foremilk and hindmilk, potentially affecting nutrition and growth.
B. It is recommended to alternate the starting breast with each feeding. Beginning with the same breast consistently can lead to engorgement on one side and may reduce stimulation and milk production in the other breast. Alternating ensures balanced milk production and comfort.
C. Breastfed infants do not require water supplementation, even in most warm climates, because breast milk provides adequate hydration. Giving water can interfere with feeding frequency, reduce caloric intake, and potentially lead to water intoxication or electrolyte imbalance in infants.
D. This reflects cue-based or demand feeding, which is the recommended approach for breastfeeding. Early hunger cues include rooting, sucking on hands, lip smacking, and increased alertness. Feeding on demand supports adequate milk supply, promotes infant growth, and improves breastfeeding success and bonding.
Correct Answer is C
Explanation
A. Autonomy refers to the client’s right to make informed decisions about their own care and treatment. In this scenario, the issue is not about the clients making choices, but about unequal distribution of healthcare resources based on insurance status, so autonomy is not the correct principle.
B. Nonmaleficence means “do no harm,” focusing on avoiding actions that cause physical or psychological harm to clients. While unequal access to supplies could indirectly contribute to poorer outcomes, the primary ethical concern in this situation is fairness in distribution of resources rather than direct harm caused by the nurse or provider.
C. Justice is the correct ethical principle. Justice refers to fairness and equitable distribution of healthcare resources. In this scenario, one client receives supplies due to insurance coverage while the other does not, creating unequal treatment based on financial status. This represents a breach of distributive justice because care and resources are not being allocated fairly to all clients with similar needs.
D. Beneficence involves actions that promote good and benefit the client. While providing supplies to the insured client may be seen as beneficial, the ethical issue here is not about promoting good but about unequal treatment, making beneficence incorrect in this context.
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