A nurse is assessing a patient who was admitted to the emergency room for chest pain. Which of the following interventions should the nurse prioritize?

Complete an electrocardiogram.

Obtain a C-reactive protein level.

Administer an anti-hypertensive medication.

Complete an echocardiogram.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Completing an electrocardiogram (ECG) is a priority in assessing a patient with chest pain to evaluate for signs of acute myocardial infarction or other cardiac abnormalities.

B. Obtaining a C-reactive protein level may be useful in certain situations to assess inflammation, but it is not a priority in the acute management of chest pain.

C. Administering an anti-hypertensive medication is not a priority unless the patient's blood pressure is significantly elevated and causing acute symptoms.

D. Completing an echocardiogram may be indicated later in the assessment process but is not typically performed immediately in the emergency room for evaluation of chest pain.

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Correct Answer is B

Explanation

Rationale:

A. Hemoptysis (coughing up blood) is not a common or expected side effect of warfarin therapy.

It may indicate a serious complication and should be reported to a healthcare provider immediately.

B. Warfarin increases the risk of bleeding, so it is important for the client to avoid activities or clothing that may increase the risk of injury or bleeding, such as tight or restrictive clothing.

C. Epistaxis (nosebleeds) can occur as a side effect of warfarin therapy due to its anticoagulant effects. While it is a potential side effect, it is not an expected outcome and should be reported to the healthcare provider.

D. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided while taking warfarin because they can increase the risk of bleeding due to their antiplatelet effects. If a headache occurs, the client should consult their healthcare provider for appropriate pain management options.

A. I should take this medication before going to bed. B. I should take one tablet at the first indication of chest pain. C. I should take one tablet every 15 minutes during an acute attack. D. I should take 1 tablet when my blood pressure is high.

Correct Answer is B

Explanation

Rationale:

A. Nitroglycerin is typically taken as needed for angina symptoms, not routinely before going to bed.

B. Taking one tablet at the first indication of chest pain is the correct instruction for using nitroglycerin to relieve angina symptoms.

C. While multiple doses of nitroglycerin may be needed during an acute angina attack, they should be spaced at least 5 minutes apart, not every 15 minutes.

D. Nitroglycerin is not typically used to lower blood pressure. It is primarily used to relieve angina symptoms by dilating blood vessels and improving blood flow to the heart.

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A nurse is assessing a patient who was admitted to the emergency room for chest pain. Which of the following interventions should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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