A patient with a history of coronary artery disease experiences chest pain while walking. After taking sublingual nitroglycerin, the patient’s chest pain increases, and they experience clammy skin and blurry vision.

They call 911 and you are the nurse attending to them in the emergency department. What is the most important nursing intervention to do first?

Administer Lasix

Increase myocardial oxygenation

Obtain one hour of echocardiogram readings

Decrease the patient’s anxiety

Answer and Explanation

The Correct Answer is B

Choice A rationale
Administering Lasix (a diuretic) would not be the most immediate intervention for a patient experiencing increased chest pain after taking sublingual nitroglycerin. Lasix is used to treat fluid retention (edema) and swelling caused by congestive heart failure, liver disease, kidney disease, and other medical conditions. It works by causing the kidneys to get rid of unneeded water and salt from the body into the urine.
Choice B rationale
The most important nursing intervention for a patient experiencing increased chest pain after taking sublingual nitroglycerin would be to increase myocardial oxygenation. This can be achieved by administering supplemental oxygen and ensuring the patient is in a position that maximizes respiratory efficiency (such as semi-Fowler’s position). This intervention addresses the immediate life-threatening situation of myocardial ischemia.
Choice C rationale
Obtaining one hour of echocardiogram readings would not be the most immediate intervention for a patient experiencing increased chest pain after taking sublingual nitroglycerin. While an echocardiogram can provide valuable information about the structure and function of the heart, it is not the first step in managing acute chest pain.
Choice D rationale
Decreasing the patient’s anxiety is an important aspect of care, but it is not the most immediate intervention for a patient experiencing increased chest pain after taking sublingual nitroglycerin. The priority is to address the physical cause of the chest pain.

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Correct Answer is D

Explanation

Choice A rationale
Venous thrombosis is a condition in which a blood clot forms in a vein, typically in the leg. While this condition can cause discomfort and changes in the appearance of the leg, it would not typically cause the leg to become cold and pale or result in the loss of a pulse.
Choice B rationale
Paresthesia refers to abnormal sensations in the body, such as tingling, numbness, or burning. While this condition could potentially cause discomfort, it would not typically cause the leg to become cold and pale or result in the loss of a pulse.
Choice C rationale
Vascular spasm is a sudden, brief tightening of the muscles inside the walls of a blood vessel. While this could potentially cause discomfort and changes in the appearance of the leg, it would not typically cause the leg to become cold and pale or result in the loss of a pulse.
Choice D rationale
Arterial occlusion is the correct answer. This condition involves a blockage in an artery, which can significantly reduce blood flow to the affected area. This could cause the leg to become cold and pale and result in the loss of a pulse.

A. Decreased blood pressure. B. Decreased urine output. C. Increased appetite. D. Increased fluid retention.

Correct Answer is A

Explanation

Choice A rationale
Vasotec, an Angiotensin-Converting Enzyme (ACE) inhibitor, is commonly used to treat conditions like high blood pressure and heart failure. It works by relaxing blood vessels, which allows blood to flow more easily and reduces blood pressure.
Choice B rationale
Decreased urine output is not a typical outcome of taking Vasotec. In fact, ACE inhibitors like Vasotec can sometimes increase urine output by improving kidney function.
Choice C rationale
Increased appetite is not a known effect of Vasotec. If a patient experiences a significant change in appetite while taking this medication, they should consult their healthcare provider.
Choice D rationale
Increased fluid retention is not a typical outcome of taking Vasotec. ACE inhibitors like Vasotec are often used to help reduce fluid retention in patients with conditions like heart failure.

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Naxlex Comprehensive Predictor Exams

An obese post-surgical patient reports sudden discomfort in her leg. Upon assessment, the nurse finds the leg to be cold and pale, with no pedal or popliteal pulse. What should the nurse suspect?

Correct Answer is D

Explanation

What positive outcome should a nurse anticipate in a patient taking Vasotec, an Angiotensin-Converting Enzyme (ACE) inhibitor?

Correct Answer is A

Explanation

The nurse is conducting a physical assessment on a client with infective endocarditis (IE). The nurse observes flat, reddened, non-tender maculae on the hands and feet. What does the nurse understand these to be?

A nurse performs Homans maneuver by flexing the knee and sharply dorsiflexing the foot. What response indicates a positive Homans sign?

A 56-year-old individual visits his primary care provider for a routine checkup.The physical examination reveals edema, an enlarged liver (hepatomegaly), and muffled heart sounds. Which of the following findings should the nurse be most concerned about?

An older patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg, consistent with acute arterial occlusion. After the nurse notifies the healthcare provider, what should the nurse do next?

In the context of Interprofessional Care of the Client and Family Across the Lifespan, a nurse is planning discharge teaching for a patient with chronic heart failure who has been prescribed digoxin (Lanoxin) and hydrochlorothiazide. What instruction should the nurse include in the teaching?

During a stress test on a treadmill, which observation by the nurse would necessitate immediate action?

What should a nurse inquire about from a patient with a past history of Deep Vein Thrombosis (DVT) and other vascular issues?