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 B

Explanation

Choice A reason:

The client states that he has trouble sleeping at night. This is subjective data because it is information that the client shares with the nurse spontaneously or in response to a question. Subjective data is based on the client's perception and feelings.

Choice B reason:

The client has a blood pressure of 150/90 mm Hg. This is objective data because it is information that the nurse observes when conducting a physical assessment. Objective data is measurable and observable.

Choice C reason:

The client reports feeling anxious about his diagnosis. This is subjective data because it is information that the client shares with the nurse spontaneously or in response to a question. Subjective data is based on the client's perception and feelings.

Choice D reason:

The client prefers not to discuss his personal issues. This is subjective data because it is information that the client shares with the nurse spontaneously or in response to a question. Subjective data is based on the client's perception and feelings.

A. The date and time of the evaluation. B. The methods used to measure outcomes. C. The revisions made to the plan of care. D. The rationale for choosing interventions. E. The comparison of outcomes with goals.

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

Explanation

Choice A reason:

The date and time of the evaluation are essential to document because they provide a reference point for the progress of the patient and the effectiveness of the nursing interventions. They also help to establish a timeline of events and facilitate communication among the health care team.

Choice B reason:

The methods used to measure outcomes are important to document because they show how the nurse assessed the patient's condition and whether the expected outcomes were met, partially met, or not met. They also provide evidence of the quality and consistency of care provided by the nurse.

Choice C reason:

The revisions made to the plan of care are necessary to document because they reflect the changes in the patient's status and needs, as well as the nurse's clinical judgment and decision making. They also demonstrate the ongoing evaluation and adaptation of the nursing care plan to achieve optimal outcomes for the patient.

Choice D reason:

The rationale for choosing interventions is not required to document because it is part of the planning phase of the nursing process, not the evaluation phase. The rationale for choosing interventions should be based on evidence-based practice, standards of care, and clinical guidelines, which are already established and available for reference.

Choice E reason:

The comparison of outcomes with goals is essential to document because it shows whether the nursing care plan was effective in addressing the patient's problems and improving the patient's condition. It also helps to identify areas of improvement, gaps in care, and opportunities for learning and feedback.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is documenting the data collected from a comprehensive physical exam of a client. Which of the following data should the nurse identify as objective data?

Correct Answer is B

Explanation

A nurse is documenting the results of an evaluation in a client's chart. Which of the following information should the nurse include? (Select all that apply.).

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

Explanation

A nurse is documenting the data collected from an assessment of a client who has a urinary tract infection (UTI). Which of the following statements should the nurse use to record objective data?

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 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 conducting an initial assessment for a client who was admitted with pneumonia. Which of the following actions should the nurse take during this phase of the nursing process?

A nurse is developing a care plan for a client who has impaired mobility due to a stroke. Which of the following actions should the nurse take first when formulating a diagnostic statement?

A nurse is performing an emergency assessment for a client who is experiencing chest pain and shortness of breath. Which of the following questions should the nurse ask the client?

Which type of intervention requires a health care provider's order?