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?

Administer ibuprofen.

Administer enteric-coated acetaminophen.

Maintain oxygen saturation greater than or equal to 92%.

Obtain an EKG.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Ibuprofen is not indicated for chest pain that may suggest myocardial infarction (MI). NSAIDs like ibuprofen can increase cardiovascular risk, thus inappropriate for suspected cardiac events. Administering ibuprofen could mask symptoms.

Choice B rationale

Enteric-coated acetaminophen is not suitable for acute chest pain related to suspected MI. It offers pain relief but does not address underlying ischemic heart disease. Immediate cardiac evaluation and intervention are required in such cases.

Choice C rationale

While maintaining oxygen saturation is essential, it does not address the need for immediate cardiac evaluation in suspected MI. Adequate oxygenation supports tissue perfusion, but it is not the definitive diagnostic or therapeutic intervention.

Choice D rationale

Obtaining an EKG is crucial for diagnosing myocardial infarction by assessing electrical activity of the heart. It helps identify ischemia or infarction. Early detection of abnormalities ensures prompt treatment and reduces complications.

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Correct Answer is ["A"]

Explanation

Choice A rationale

Pregnancy increases venous pressure, leading to stasis and a higher risk of DVT due to hormonal changes and decreased venous return.

Choice B rationale

Oral contraceptive use elevates estrogen levels, increasing blood coagulability and the risk of clot formation, predisposing individuals to DVT.

Choice C rationale

Trauma can damage blood vessel walls, initiating clotting cascades and increasing the likelihood of deep vein thrombosis formation.

Choice D rationale

Immobility causes venous stasis, as muscle contractions that promote blood return are reduced, heightening the risk of DVT due to stagnant blood flow.

A. The test will be complete in 30 to 60 minutes. B. I will need to apply electrodes to your chest and extremities. C. You might feel a slight tingling while the test is being done. D. The radioactivity from the dye lasts only a few hours.

Correct Answer is B

Explanation

Choice A rationale

ECG tests usually take 5 to 10 minutes to complete. The patient's chest pain necessitates a quick assessment, and prolonged testing could delay urgent care.

Choice B rationale

Electrodes applied to the chest and extremities detect the electrical activity of the heart, necessary for accurate ECG readings and diagnosing potential cardiac issues.

Choice C rationale

The ECG procedure does not typically cause tingling sensations. It involves passive measurement of electrical signals, making this statement inaccurate and potentially alarming to the patient.

Choice D rationale

ECG tests do not involve dye or radioactivity. This confusion may arise from nuclear stress tests, which are different procedures for evaluating heart function.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

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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?