A nurse in the emergency department is assessing a client who has a history of angina and reports chest pain. Which of the following findings is the priority?

Three doses of nitroglycerin relieve the client's pain.

Pain radiates to the client's left arm.

Pain began in the morning while the client was resting.

Pain is greatest in the client's substernal chest area.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Three doses of nitroglycerin relieve the client's pain: While nitroglycerin can relieve chest pain related to angina, the fact that the pain subsides after three doses may indicate stable angina. However, this does not address the underlying concern if the pain began at rest, which is more concerning.

B. Pain radiates to the client's left arm: Pain radiating to the left arm is a common symptom of angina or myocardial infarction (MI). While this is concerning, it is not the most urgent finding compared to the pain onset, especially when pain occurs at rest.

C. Pain began in the morning while the client was resting: Chest pain occurring at rest, especially in the morning, is the most concerning symptom. This could indicate unstable angina or an impending myocardial infarction (MI). Unstable angina is more dangerous than stable angina and requires immediate intervention.

D. Pain is greatest in the client's substernal chest area: Substernal chest pain is characteristic of angina, but it is not as concerning as the timing of pain onset. Pain at rest, especially in the morning, suggests unstable angina or MI, which is a higher priority.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["C","D","E","G"]

Explanation

Rationale:

A. Blood glucose level: The blood glucose level of 103 mg/dL is within normal limits (74 to 106 mg/dL) and does not require immediate follow-up. While the client has type 2 diabetes mellitus, the blood glucose is not abnormal at this time.

B. Bowel sounds: Bowel sounds are present in all four quadrants and do not require immediate follow-up. This finding is normal and is unrelated to the acute symptoms being assessed for a possible myocardial infarction.

C. Blood pressure: The client’s blood pressure is elevated at 164/80 mm Hg, which requires immediate attention in the context of chest pain and other symptoms that may suggest an acute myocardial infarction (MI).

D. Pain level: The client rates their chest pain as 7 out of 10, which is significant and consistent with potential myocardial ischemia or infarction. The pain’s radiation to the left arm, along with other symptoms like nausea and diaphoresis, suggest an urgent need for intervention.

E. Electrocardiogram findings: The 12-lead ECG shows tachycardia, ST segment elevation, and T wave changes, which are indicative of acute myocardial injury, such as an ST-elevation myocardial infarction (STEMI). This requires immediate intervention to prevent further myocardial damage.

F. Lung sounds: The lung sounds are clear in all lobes, which is reassuring and does not indicate an immediate concern.

G. Troponin T level: The elevated Troponin T level (0.40 ng/mL) is a key biomarker for myocardial injury. The elevation indicates ongoing cardiac damage, which requires immediate follow-up to assess for the extent of the infarction and initiate treatment.

A. Decontaminate hands with an alcohol-based hand rub after taking the client's pulse. B. Dry hands by starting from the wrist and moving toward the fingers. C. Wash hands with an alcohol-based hand rub if you have artificial nails. D. Lather hands with soap and apply friction under running water for 5 seconds.

Correct Answer is A

Explanation

Rationale:

A. Decontaminate hands with an alcohol-based hand rub after taking the client's pulse:
Alcohol-based hand rubs are effective for decontaminating hands after routine tasks like taking a pulse, provided hands are not visibly soiled. They are effective in removing most pathogens, making them ideal.

B. Dry hands by starting from the wrist and moving toward the fingers: Hands should be dried by patting them gently with a clean paper towel, starting from the fingers and moving toward the wrist. This technique reduces the risk of transferring pathogens to clean areas.

C. Wash hands with an alcohol-based hand rub if you have artificial nails: Alcohol-based hand rubs should not be used if artificial nails are present, as they may not effectively remove pathogens from under the nails. Handwashing with soap and water is preferred in these cases.

D. Lather hands with soap and apply friction under running water for 5 seconds: Handwashing should involve lathering with soap for at least 20 seconds, not 5, to ensure that friction is applied across all areas of the hands to remove pathogens effectively.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse in the emergency department is assessing a client who has a history of angina and reports chest pain. Which of the following findings is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Exhibits The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up.

Correct Answer is ["C","D","E","G"]

Explanation

A nurse is teaching a group of assistive personnel about performing hand hygiene when caring for a client who has an immunodeficiency disorder. Which of the following information should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is caring for a client who has advanced liver disease. Which of the following laboratory results should the nurse monitor when assessing this client?

The nurse is caring for a client in the emergency department. Exhibits Which of the following interventions should the nurse perform?

A nurse is monitoring a client's heart rhythm following insertion of a permanent pacemaker. Which of the following images should the nurse expect?

A nurse is caring for a client in the emergency department. Exhibits For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process.

A home health nurse is assessing a client who has COPD. Which of the following findings indicates the need for a referral for pulmonary rehabilitation?

A nurse is caring for a client who has heart failure. Exhibits

A nurse is caring for a client who is postoperative following a total knee arthroplasty. The client tells the nurse, "I will not be able to play with my grandchildren anymore." Which of the following responses should the nurse make?

A nurse is performing a skin assessment for a client who has been on bed rest for 1 week. The nurse notes reddened areas on the client's scapulae. Which of the following actions should the nurse take?