A nurse is caring for a 58-year-old male client in the emergency department (ED) who presents with an irregular pulse and elevated blood pressure.

Exhibits

The nurse is planning care for the client. For each potential prescription, indicate whether it is indicated, nonessential, or contraindicated.

Administer O2 to maintain oxygen saturation greater than 90%.

Prepare the client for intubation.

Apply continuous ECG monitoring.

Obtain the client’s family history.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"}}

Rationales:

Administer O2 to maintain oxygen saturation greater than 90%: This prescription is indicated. Hypoxia can exacerbate cardiac and respiratory issues, so it is essential to maintain adequate oxygen levels in the blood. Supplemental oxygen can help improve tissue oxygenation and reduce strain on the heart.
Apply continuous ECG monitoring: This prescription is indicated. Continuous ECG monitoring is crucial in detecting arrhythmias and ischemic changes in a patient with cardiac symptoms and irregular pulse. Early detection allows for timely intervention and management of potentially life-threatening cardiac events.
Obtain the client’s family history: This prescription is nonessential. While obtaining a family history is useful for identifying potential genetic predispositions to cardiac and metabolic conditions, it is not immediately necessary for the acute management of the client’s current symptoms.
Prepare the client for intubation: This prescription is contraindicated. The client is currently maintaining an adequate respiratory rate and oxygen saturation on room air. There is no indication of respiratory failure or inability to maintain airway patency. Intubation would be an unnecessarily invasive procedure at this time.

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 D

Explanation

Choice A rationale

A QRS duration of 0.30 seconds is abnormally long. The normal QRS duration is 0.06 to 0.12 seconds, indicating this is not normal sinus rhythm.

Choice B rationale

An inverted T wave is not a characteristic of normal sinus rhythm. It may indicate ischemia or other cardiac abnormalities.

Choice C rationale

A P-R interval of 0.32 seconds is prolonged. The normal P-R interval is 0.12 to 0.20 seconds, thus indicating an abnormal rhythm.

Choice D rationale

The P wave falling before the QRS complex is a key characteristic of normal sinus rhythm, representing the orderly conduction of electrical impulses from atria to ventricles. .

A. Administer oxygen to maintain oxygen saturation greater than 94%. B. Prepare the client for intubation. C. Apply continuous ECG monitoring. D. Obtain the client’s family history.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

Choice A - Indicated:

Administering oxygen to maintain oxygen saturation >94% is recommended in suspected acute coronary syndrome (ACS) to prevent myocardial hypoxia.
Oxygen therapy is not routinely given if SpO₂ is ≥94%, but if there are signs of hypoxia, respiratory distress, or low saturation, it is appropriate.

Choice B - Contraindicated:

Intubation is not indicated unless the patient has severe respiratory distress or impending respiratory failure.
This client is not in respiratory failure (no severe dyspnea, altered consciousness, or worsening hypoxia).

Choice C - Indicated:

Continuous ECG monitoring is essential in suspected ACS to detect arrhythmias, ischemia, and ST changes.
ECG findings will guide early intervention, including medication administration (e.g., aspirin, nitroglycerin) or reperfusion therapy.

Choice D - Nonessential:

Family history of cardiovascular disease is important for risk assessment but is not a priority in an acute setting.
While it can help with long-term management, immediate interventions (oxygen, ECG, medications) take precedence.

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 is caring for a 58-year-old male client in the emergency department (ED) who presents with an irregular pulse and elevated blood pressure. Exhibits The nurse is planning care for the client. For each potential prescription, indicate whether it is indicated, nonessential, or contraindicated.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

A nurse is teaching a newly licensed nurse about evaluating a cardiac rhythm.Which of the following options should the nurse identify as the P wave in the ECG complex?

A nurse is providing teaching to a client who has a family history of hypertension.The nurse should inform the client that his blood pressure of 124/85 mm Hg places him in which of the following categories?

A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker.Which of the following prescriptions should the nurse clarify?

A nurse is caring for a 58-year-old male client in the emergency department (ED) who presents with an irregular pulse and elevated blood pressure. Exhibits The nurse is planning care for the client. For each potential prescription, indicate whether it is indicated, nonessential, or contraindicated.

A nurse is assessing a client who has atrial fibrillation.Which of the following pulse characteristics should the nurse expect?

A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shoulder, shortness of breath, and nausea.Which of the following actions should the nurse take?

A nurse is teaching a client who has angina about nitroglycerin sublingual tablets.Which of the following statements should the nurse include in the teaching?

A nurse is admitting a client who has acute heart failure following a myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification?