A nurse in the emergency department is caring for a client.
The nurse reviews the client’s medical record. Select the 4 actions the nurse should take.
Request a prescription for a sputum culture.
Perform a 12-lead ECG.
Prepare to administer antiplatelet therapy.
Obtain arterial blood gases.
Prepare the client for a cardiac catheterization.
Administer oxygen at 2 L/min nasal cannula.
Correct Answer : B,C,E,F
A. Sputum cultures are indicated for suspected respiratory infections, not myocardial infarction. This is incorrect.
B. A 12-lead ECG is the first diagnostic test for chest pain to identify ST-segment elevation or ischemic changes indicating myocardial infarction.
C. Antiplatelet therapy (e.g., aspirin) prevents further platelet aggregation and thrombus formation, which improves coronary blood flow during acute coronary syndromes.
D. ABGs may provide information about oxygenation, but are not routinely required unless severe respiratory compromise or acidosis is suspected. Priority is oxygen and cardiac assessment.
E. Preparing for cardiac catheterization (coronary angiography) is appropriate since this client shows positive troponins and unrelieved chest pain, indicating myocardial infarction requiring reperfusion evaluation.
F. Oxygen administration at 2 L/min via nasal cannula helps improve oxygenation (SpO₂ 89%) and reduces myocardial ischemia. Maintaining SpO₂ ≥ 90% is essential to minimize cardiac workload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Having a UAP stay daily is not realistic or necessary for all elderly clients. Home assistance is typically scheduled for specific needs, not for constant presence.
B. Weekly contact with family offers emotional support but does not ensure safety in case of a fall or emergency.
C. A personal emergency response system (PERS) enables the client to quickly summon help after a fall or medical emergency. This promotes safety and independence while addressing the client’s anxiety about living alone.
D. Moving to a skilled nursing facility is not indicated solely due to fear of falling. Interventions should first focus on maintaining safety and independence in the client’s current home.
Correct Answer is B
Explanation
Rationale:
A. Salty or spicy foods can irritate oral lesions and increase pain.
B. Using ice chips or cold foods helps numb oral mucosa and reduce pain caused by stomatitis or oral candidiasis, which are common in clients with AIDS. Cool, soft, bland foods are best tolerated.
C. Hot foods can further irritate mucosal tissues and increase discomfort.
D. Alcohol-based mouthwash causes dryness and irritation, worsening oral lesions. A nonalcoholic mouth rinse such as saline or sodium bicarbonate solution should be recommended.
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