A patient arrives at the clinic reporting a new onset of angina pectoris that has persisted for the last 30 minutes. What should be the nurse’s initial action?
Administer a nebulizer treatment.
Obtain an EKG reading.
Review the patient’s surgical history.
Record the patient’s weight.
The Correct Answer is B
Choice A rationale
Administering a nebulizer treatment would be more appropriate for respiratory conditions such as asthma or COPD, not for angina pectoris.
Choice B rationale
Obtaining an EKG reading is the most appropriate initial action when a patient reports a new onset of angina pectoris. An EKG can help determine if the patient is experiencing a myocardial infarction (heart attack), which is a life-threatening condition.
Choice C rationale
While reviewing the patient’s surgical history is important in a comprehensive assessment, it is not the most immediate action needed when a patient presents with angina.
Choice D rationale
Recording the patient’s weight is not the most immediate action needed when a patient presents with angina.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The client reports mild pain in the upper left arm at 2/10 on a scale of 0 to 10. This indicates that the interventions were effective in managing the pain associated with the infection and cellulitis.
Choice B rationale
The client’s early morning finger stick blood glucose (FSBG) was 97 mg/dL (5.4 mmol/L). This is within the normal range, indicating that the interventions were effective in maintaining the client’s blood glucose levels within the normal range.
Choice C rationale
The client’s left upper arm is slightly reddened when compared with the right upper arm. This could be a sign of inflammation or infection, suggesting that the interventions were ineffective in completely resolving the infection and cellulitis.
Choice D rationale
The client reports that her back is more achy since she came to the hospital. This could be due to a variety of factors, including the hospital bed or a lack of physical activity. It is unrelated to the expected outcomes of the interventions for the infection and cellulitis.
Correct Answer is C
Explanation
Choice A rationale
Advocacy in nursing refers to supporting, promoting, and protecting the rights, safety, and wellbeing of patients. While it is important for nurses to be able to explain their practice, this scenario does not specifically illustrate advocacy.
Choice B rationale
Autonomy in nursing refers to the right of patients to make informed decisions about their medical care. This scenario does not specifically illustrate autonomy.
Choice C rationale
Accountability in nursing refers to being answerable for one’s actions and practice. The ability to explain one’s practice to patients and employers is a key aspect of accountability.
Choice D rationale
Responsibility in nursing refers to the obligations and duties that come with the nursing role. While being able to explain one’s practice is part of a nurse’s responsibilities, it is more directly related to accountability.
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