A patient with coronary artery disease (CAD) is admitted to the medical unit for testing.
The patient reports frequent episodes of angina over the past few days and is currently experiencing shortness of breath, nausea, and chest pressure.
After obtaining the patient’s vital signs, what should be the nurse’s next course of action?

Count and record the number of premature ventricular contractions per minute.

Apply oxygen via nasal cannula and adjust to maintain oxygen saturation above 93%.

Ensure troponin level assessments are scheduled every 3 to 6 hours for a series of three.

Initiate dim lighting, lower alarm volumes, and control traffic in and out of the room area.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Counting and recording the number of premature ventricular contractions per minute is not the immediate priority for a patient experiencing symptoms of angina and shortness of breath. While it is important to monitor the patient’s heart rhythm, the immediate priority is to address the patient’s symptoms and stabilize their condition.

Choice B rationale

Applying oxygen via a nasal cannula and adjusting to maintain oxygen saturation above 93% is the immediate priority for a patient experiencing symptoms of angina and shortness of breath. Oxygen therapy can help to relieve the symptoms of angina and improve the patient’s oxygen saturation.

Choice C rationale

Ensuring troponin level assessments are scheduled every 3 to 6 hours for a series of three is important for diagnosing a heart attack, but it is not the immediate priority. The immediate priority is to address the patient’s symptoms and stabilize their condition.

Choice D rationale

Initiating dim lighting, lowering alarm volumes, and controlling traffic in and out of the room area can help to create a calm and quiet environment for the patient. However, this is not the immediate priority. The immediate priority is to address the patient’s symptoms and stabilize their condition.

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Correct Answer is A

Explanation

Choice A rationale

The patient’s history indicates that she had difficulty breathing during a hike. This event led her to the emergency department. Difficulty breathing during physical activity such as hiking can be a symptom of an asthma exacerbation.

Choice B rationale

While severe allergic reactions can cause difficulty breathing, the patient’s history does not indicate that she experienced an allergic reaction prior to her emergency department visit.

Choice C rationale

Panic attacks can cause symptoms such as rapid heart rate, sweating, and shortness of breath. However, the patient’s history does not indicate that she had a panic attack prior to her emergency department visit.

Choice D rationale

Fainting, or loss of consciousness, can be caused by various conditions, including dehydration, low blood sugar, and heart problems. However, the patient’s history does not indicate that she fainted prior to her emergency department visit.

A. Cefazolin 1 gram intravenously every 6 hours. B. Complete blood cell count (CBC) in the morning. C. Straight catheterization if unable to void. D. Advance from clear liquids as tolerated.

Correct Answer is A

Explanation

The correct answer is A. The nurse should first implement the prescription of Cefazolin 1 gram intravenously every 6 hours.

This is because, on admission of a patient to the postanesthesia care unit (PACU) from surgery, the first priority is to assess the airway and breathing status. Administering Cefazolin, an antibiotic, helps prevent postoperative infections, which is crucial in the immediate postoperative period.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is admitting a client from the postanesthesia unit to the postoperative surgical care unit.Which prescription should the nurse implement first?

Correct Answer is A

Explanation

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management.Which response by the client indicates understanding?

A patient with a recent exacerbation of heart failure is feeling uncomfortable and anxious, with a sensation of flopping in the chest.While waiting for an electrocardiogram (ECG), which assessment should the nurse prioritize?

A client is two hours postoperative from a cardiac catheterization via the right femoral artery.Which assessment finding indicates arterial obstruction?

After administering the prescribed albuterol nebulizer treatment, what should the nurse assess?

A patient admitted with an acute coronary syndrome (ACS) is receiving eptifibatide, a glycoprotein (GP) IIb IIIa inhibitor.Which assessment finding poses the greatest risk to the patient?

A patient informs the nurse about starting an exercise program a month ago to lose weight and improve sleep.The patient states, “It still takes at least two hours to fall asleep at night.”. What action should the nurse take?

A patient with a history of celiac disease has recently been diagnosed with multiple sclerosis.The nurse is preparing to discharge the patient.What is the most important instruction for the nurse to include in the discharge teaching plan?