A nurse is caring for a patient who has just been admitted to the hospital with chest pain and shortness of breath. The patient has a history of coronary artery disease and hypertension. The nurse obtains vital signs, performs an electrocardiogram (ECG), and administers oxygen therapy as ordered by the physician. What is the next priority action for the nurse?

Administer nitroglycerin sublingually as ordered.

Obtain a complete health history from the patient.

Educate the patient about lifestyle modifications.

Prepare the patient for cardiac catheterization.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Administering nitroglycerin sublingually as ordered is the next priority action for the nurse because nitroglycerin is a medication that relaxes the heart arteries and improves blood flow to the heart muscle, which can relieve chest pain and shortness of breath caused by coronary artery disease. Nitroglycerin can also lower blood pressure, which can help reduce the workload of the heart and prevent further damage to the heart muscle. Nitroglycerin is a fast-acting medication that should be given as soon as possible after chest pain occurs or is suspected.

Choice B reason:

Obtaining a complete health history from the patient is not the next priority action for the nurse because it is not an urgent intervention that can address the patient's immediate needs. A complete health history can provide valuable information about the patient's risk factors, past medical history, medications, allergies, and family history, but it can also take a long time to obtain and may not be feasible if the patient is in pain or distress. A complete health history can be obtained later after the patient's condition is stabilized and more urgent interventions are done.

Choice C reason:

Educating the patient about lifestyle modifications is not the next priority action for the nurse because it is not an acute intervention that can relieve the patient's symptoms or prevent further complications. Lifestyle modifications such as quitting smoking, eating a healthy diet, exercising regularly, managing stress, and controlling blood pressure and cholesterol levels are important for preventing or managing coronary artery disease in the long term, but they do not have an immediate effect on the patient's condition. Educating the patient about lifestyle modifications can be done later after the patient's condition is improved and the patient is ready to learn.

Choice D reason:

Preparing the patient for cardiac catheterization is not the next priority action for the nurse because it is not a definitive intervention that can confirm or rule out coronary artery disease or other causes of chest pain and shortness of breath. Cardiac catheterization is a diagnostic procedure that involves inserting a thin tube into an artery in the groin or arm and advancing it to the heart to inject contrast dye and take X-ray images of the heart and blood vessels. Cardiac catheterization can help identify blockages or narrowing in the coronary arteries that may cause chest pain and shortness of breath, but it also carries some risks such as bleeding, infection, allergic reaction, kidney damage, or heart attack. Cardiac catheterization may be ordered by the physician after other tests such as ECG, blood tests, or.

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Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason:

Comparing data with normal values and standards is an important action for the nurse to take during the assessment phase of the nursing process. This helps the nurse to identify any deviations from normal and potential problems that need further investigation or intervention.

Choice B reason:

Organizing data into clusters that have similar underlying causes is another action that the nurse should take during the assessment phase. This helps the nurse to recognize patterns and relationships among the data and to formulate nursing diagnoses.

Choice C reason:

Validating data by using multiple sources of information is also an action that the nurse should take during the assessment phase. This helps the nurse to ensure that the data are accurate, complete, and factual, and to avoid making assumptions or errors.

Choice D reason:

Documenting data using standardized terminology and abbreviations is not an action that the nurse should take during the assessment phase of the nursing process. Although documentation is an essential part of nursing practice, it is not specific to the assessment phase. Moreover, standardized terminology and abbreviations are not always appropriate or clear for documenting data.

Choice E reason:

Prioritizing data according to urgency and importance is another action that the nurse should take during the assessment phase of the nursing process. This helps the nurse to focus on the most relevant and significant data and to plan for further assessment or intervention based on the patient's needs and priorities.

A. The nurse uses a mechanical lift to transfer the client from bed to chair. B. The nurse performs passive range of motion exercises for the affected limbs. C. The nurse encourages the client to participate in physical therapy sessions. D. The nurse applies antiembolic stockings and sequential compression devices to the lower extremities.

Correct Answer is A

Explanation

Choice A reason:

The nurse uses a mechanical lift to transfer the client from bed to chair. This is the correct answer because it demonstrates the use of appropriate resources and equipment to prevent injury to the client and the nurse, and to facilitate safe mobility for the client who has impaired mobility due to a stroke. A mechanical lift is a device that helps lift and move a person who cannot move on their own or with minimal assistance.

Choice B reason:

The nurse performs passive range of motion exercises for the affected limbs. This is not the correct answer because it does not demonstrate the use of appropriate resources and equipment, but rather a nursing intervention that helps maintain joint mobility, prevent contractures, and improve circulation for the client who has impaired mobility due to a stroke. Passive range of motion exercises are movements that are done by someone else for a person who cannot move their own limbs.

Choice C reason:.

The nurse encourages the client to participate in physical therapy sessions. This is not the correct answer because it does not demonstrate the use of appropriate resources and equipment, but rather a nursing intervention that helps promote recovery, prevent complications, and improve function for the client who has impaired mobility due to a stroke. Physical therapy is a type of rehabilitation that involves exercises and activities that help improve strength, balance, coordination, and mobility.

Choice D reason:

The nurse applies antiembolic stockings and sequential compression devices to the lower extremities. This is not the correct answer because it does not demonstrate the use of appropriate resources and equipment, but rather a nursing intervention that helps prevent deep vein thrombosis (DVT), a potential complication of stroke that occurs when a blood clot forms in a vein deep in the body. Antiembolic stockings are tight-fitting elastic socks that apply pressure to the legs and feet to improve blood flow and prevent clotting. Sequential compression devices are inflatable sleeves that wrap around the legs and inflate and deflate periodically to squeeze the veins and improve blood flow.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is using critical thinking skills to analyze data during the assessment phase of the nursing process. Which of the following actions should the nurse take?(Select all that apply).

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is using appropriate resources and equipment when implementing care for a client who has impaired mobility due to a stroke. Which of the following actions by the nurse demonstrates this skill?

Correct Answer is A

Explanation

A nurse is conducting an assessment on a client who has multiple sclerosis (MS). Which of the following data should the nurse collect? (Select all that apply.).

A nurse is conducting a problem-focused assessment for a client who reports nausea and vomiting. Which of the following statements should the nurse make to gather more information about the problem?

A nurse is performing an ongoing assessment for a client who has a pressure ulcer. Which of the following data should the nurse collect? (Select all that apply).

A nurse is developing a plan of care for a client who has diabetes mellitus. Which of the following actions should the nurse take first?

A nurse is recognizing errors or omissions in a plan of care for a client with chronic kidney disease who is on hemodialysis. Which of the following actions should the nurse take?

Which of these are characteristics of a well-written outcome?(Select all that apply.)

Which of these is an example of a goal rather than an outcome?

A nurse is preparing a diagnostic statement for a client who has chronic obstructive pulmonary disease (COPD) and reports shortness of breath and fatigue with minimal exertion. Which of the following formats should the nurse use to write the statement?