A nurse is caring for a client in the emergency department (ED). The client presents with substernal chest pain that comes and goes.

The client states that the pain has been occurring for the last 6 hours.

The pain, at times, radiates down the left arm.

The client also reports intermittent nausea.

The client appears pale and slightly diaphoretic.

The client rates current pain as 8 on a scale of 0 to 10. The nurse is planning care for the client.

For each potential prescription, indicate whether it is indicated, nonessential, or contraindicated.

Administer oxygen to maintain oxygen saturation greater than 94%.

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"}}

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.

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Correct Answer is C

Explanation

Choice A rationale

Slow repolarization of ventricular Purkinje fibers is not associated with the P wave. The P wave represents atrial depolarization, which is the electrical activation of the atria.

Choice B rationale

Early ventricular repolarization is represented by the T wave, not the P wave. The P wave specifically reflects atrial depolarization.

Choice C rationale

Atrial depolarization is the correct role of the P wave. It represents the electrical activity that leads to atrial contraction. Normal duration is 0.06 to 0.12 seconds.

Choice D rationale

Ventricular depolarization is represented by the QRS complex. The P wave precedes this and is related to atrial depolarization, not ventricular events.

A. Assess pulses in the client’s affected arm. B. Keep the client NPO for at least 2 hours following the procedure. C. Apply light pressure to the insertion site. D. Encourage the client to ambulate within 30 minutes following the procedure.

Correct Answer is A

Explanation

Choice A rationale

Assessing pulses in the affected arm ensures proper blood flow and identifies potential complications like arterial occlusion following cardiac catheterization. Monitoring for changes can prevent severe outcomes. Normal pulse rates: 60-100 bpm.

Choice B rationale

Keeping the client NPO post-procedure is unnecessary as food and liquids can typically be resumed once the patient is stable, unless specific medical instructions indicate otherwise.

Choice C rationale

Light pressure on the insertion site is insufficient for hemostasis. Firm pressure for 10-15 minutes is necessary to prevent bleeding and hematoma formation, especially in arterial catheterization sites.

Choice D rationale

Immediate ambulation post-cardiac catheterization risks bleeding and hematoma at the insertion site. Bed rest and activity restrictions should be maintained until hemostasis is confirmed, typically for 2-6 hours.

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Naxlex Comprehensive Predictor Exams

A nurse is interpreting the ECG strip of a client who has bradycardia.Which of the following cardiac components should the nurse identify as the role of the P wave?

Correct Answer is C

Explanation

A nurse is evaluating a client who had a left-sided cardiac catheterization with an upper extremity insertion site.Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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 providing teaching for a client who has a new diagnosis of angina pectoris.Which of the following information should the nurse include about anginal pain?

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 reviewing the serum laboratory findings for a client who has hypertension and is prescribed hydrochlorothiazide.Which of the following findings should the nurse report to the provider?

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 reports an area of redness, warmth, tenderness and pain in the right calf.The nurse anticipates which of the following orders when notifying the provider of this finding?

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 teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client.Which of the following statements should the nurse make regarding cardiac enzyme studies?