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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Exercise is an important part of managing type 2 diabetes as it helps regulate blood glucose levels. When you exercise, your muscles use sugar (glucose) for energy. Regular physical activity also helps your body use insulin more efficiently. Therefore, the statement “Remember exercise will not affect blood glucose levels” is incorrect.
Choice B rationale
Moderate alcohol consumption is generally safe for most people with diabetes. A moderate amount of alcohol is up to one drink a day for women of all ages and men older than age 65, and up to two drinks a day for men age 65 and younger. Too much alcohol can cause blood sugar levels to drop too low and can also increase the risk of other health problems.
Choice C rationale
While it’s important to keep wounds clean and covered, using antibiotic ointment on every wound isn’t always necessary. Overuse of antibiotics can lead to antibiotic resistance. It’s best to consult with a healthcare provider for wound care advice.
Choice D rationale
Soaking feet in hot water can lead to burns or infections, especially if the person has neuropathy. It’s recommended to wash feet with warm — not hot — water and dry them gently, especially between the toes.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"}}
Explanation
Based on the provided information, here are the interventions the nurse should perform:
- Check capillary refill on bilateral upper extremities.- Indicated: This is important to assess the client’s circulation, especially given the coolness of the left arm and the fracture in the left shoulder.
- Administer ondansetron 4 mg IV.- Contraindicated: There is no prescription for ondansetron and no indication of nausea or vomiting from the client.
- Inspect the bandage for drainage.- Indicated: Given the client’s recent surgery and the presence of swelling and bruising, it’s important to monitor for any signs of infection or complications.
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