A nurse in the emergency department is caring for a client who presents with non-ST elevation myocardial infarction (NSTEMI). Which of the following actions should the nurse take first?

Attach the leads for continuous cardiac monitoring

Initiate oxygen therapy

Insert the IV catheter

Obtain a blood sample

Answer and Explanation

The Correct Answer is A

Choice A reason: Attaching leads for continuous cardiac monitoring is the first action in NSTEMI, as it allows real-time assessment of heart rhythm and ischemia. NSTEMI can lead to arrhythmias or worsening ischemia, and monitoring enables rapid detection of life-threatening changes, guiding timely interventions to stabilize the client’s condition.

Choice B reason: Initiating oxygen therapy is important if the client is hypoxic, but it is not the first action. Continuous cardiac monitoring takes priority to detect arrhythmias or ischemic changes in NSTEMI, which can be immediately life-threatening. Oxygen can be administered after monitoring is established if indicated.

Choice C reason: Inserting an IV catheter is necessary for administering medications like antiplatelets or anticoagulants in NSTEMI but is not the first action. Continuous cardiac monitoring is prioritized to detect acute rhythm or ischemic changes, which guide treatment decisions and ensure timely management of potentially fatal complications.

Choice D reason: Obtaining a blood sample for cardiac biomarkers like troponin is important to confirm NSTEMI severity but is not the first action. Continuous cardiac monitoring takes precedence, as it provides immediate data on heart rhythm and ischemia, enabling rapid response to life-threatening changes in the client’s condition.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Kernig’s sign is a clinical indicator of meningitis, characterized by pain and resistance when extending the leg from a flexed position at the hip and knee. This occurs due to inflammation of the meninges, which causes irritation of the spinal nerve roots, leading to muscle stiffness and discomfort during leg extension, reflecting meningeal irritation.

Choice B reason: Brudzinski’s sign involves involuntary flexion of the hips and knees when the neck is flexed, indicating meningeal irritation in meningitis. It differs from Kernig’s sign, as it is elicited by neck movement rather than leg extension. While both signs suggest meningitis, Brudzinski’s sign is not observed in the described leg extension scenario.

Choice C reason: Nuchal rigidity refers to neck stiffness, a common meningitis symptom, where the client resists neck flexion due to meningeal inflammation. Unlike Kernig’s sign, it is not associated with leg movement. It reflects irritation of the meninges but is not the specific condition observed during the leg extension test described in the scenario.

Choice D reason: Bradykinesia, characterized by slow movement, is typically associated with neurological disorders like Parkinson’s disease, not meningitis. It involves impaired motor control due to basal ganglia dysfunction, unrelated to meningeal inflammation or leg extension pain. Therefore, it does not correspond to the clinical presentation described in the meningitis assessment scenario.

A. Wearing the sequential compression device B. Elevating their feet C. Massaging their legs D. Ambulating soon after surgery

Correct Answer is C

Explanation

Choice A reason: Wearing a sequential compression device is recommended post-surgery to prevent venous thromboembolism. It promotes venous blood flow in the legs, reducing stasis, a key risk factor for clot formation. This action supports VTE prevention by enhancing circulation, making it appropriate and not to be avoided.

Choice B reason: Elevating the feet post-surgery aids venous return, reducing blood pooling in the legs, a risk factor for venous thromboembolism. This action decreases stasis and supports circulation, making it a beneficial practice for VTE prevention, not one to avoid in postoperative recovery.

Choice C reason: Massaging the legs should be avoided post-surgery, as it risks dislodging a formed clot, potentially causing a pulmonary embolism. In clients at risk for VTE, massage can mobilize thrombi from deep veins, leading to life-threatening complications, making this a critical action to avoid.

Choice D reason: Ambulating soon after surgery is encouraged to prevent venous thromboembolism. Early mobility promotes venous blood flow, reducing stasis, a major risk factor for clot formation. This action supports circulation and VTE prevention, making it appropriate and not something to avoid in postoperative care.

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 caring for a client who presents with non-ST elevation myocardial infarction (NSTEMI). Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has meningitis and notices the client grimace in pain when extending the leg from a flexed position. Which of the following conditions is the client displaying?

Correct Answer is A

Explanation

A nurse is recovering a client who is postoperative. In an effort to educate the client about being at risk for developing a venous thromboembolism (VTE), which of the following actions should the client avoid?

Correct Answer is C

Explanation

A nurse is admitting a young adult client who has suspected bacterial meningitis. The nurse should closely monitor the client for increased intracranial pressure (ICP) as indicated by which of the following findings?

A newly licensed nurse is assessing a client who had a cardiac catheterization with a right femoral insertion site. Which of the following pulses should the nurse palpate?

A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm?

A nurse is caring for a client who just had a cardiac catheterization through the left femoral vessel. Which of the following nursing interventions should the nurse include in the client’s plan of care? (Select all that apply)

A nurse is caring for a client who is scheduled for an exercise stress test. Which of the following comments made by the client should indicate to the nurse that the client requires further teaching?

A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider?

A client was brought to the emergency department for severe chest pain despite nitroglycerin and aspirin administration in the ambulance. Which of the following findings would suggest myocardial infarction (MI) with cardiac tissue injury?