An emergency department nurse is collecting information from a client who has stable vital signs when their other client begins to report chest pain. Which of the following should be the nurse's priority?

Call the client's home for someone to pick up the client.

Call for a code blue.

Ask another nurse to assess the client who reports chest pain.

Alert the RN to assess the client reporting chest pain

Answer and Explanation

The Correct Answer is C

A. Call the client's home for someone to pick up the client. This is not appropriate in an emergency situation. The client reporting chest pain needs immediate attention, and arranging for pick-up is not a priority.

B. Call for a code blue. Code blue is reserved for clients in cardiac or respiratory arrest. The nurse needs to assess the severity of the chest pain first before calling a code.

C. Ask another nurse to assess the client who reports chest pain. The priority is to ensure that the client reporting chest pain is assessed immediately. Delegating this task to another nurse allows prompt care for the client with potential cardiac issues while ensuring that the first client continues to receive care.

D. Alert the RN to assess the client reporting chest pain: While notifying the RN is important, it may delay the initial assessment and intervention needed for the client with chest pain. Delegating to another available nurse is a more immediate action.

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Correct Answer is B

Explanation

A. "It usually takes at least 2 to 3 days for heparin to dissolve a clot." Heparin does not dissolve clots; it prevents the formation of new clots and stops existing clots from growing.

B. "Heparin prevents new clots from forming rather than dissolving established clots." Heparin's role is to prevent new clots from forming, not to dissolve existing clots. The body's natural fibrinolytic system will eventually break down the clot.

C. "The time it takes for heparin to dissolve a clot depends on the size of the clot." This is incorrect because heparin does not dissolve clots, regardless of their size.

D. "The time it takes heparin to dissolve clots varies between clients." This is incorrect as well, as heparin does not dissolve clots at all.

A. Troponin T B. Creatinine phosphokinase C. Myoglobin D. Creatinine kinase-MB

Correct Answer is A

Explanation

A. Troponin T: Troponin T remains elevated for 10 to 14 days after a myocardial infarction. This protein is highly specific for cardiac muscle injury and is used to confirm myocardial infarction.

B. Creatinine phosphokinase: Creatinine phosphokinase (CPK) typically returns to normal levels within 3 days after a myocardial infarction, so it would no longer be elevated at this point.

C. Myoglobin: Myoglobin rises early after a myocardial infarction but is not specific to heart muscle and returns to normal within 24 hours, so it would not be elevated at this time.

D. Creatinine kinase-MB: Creatinine kinase-MB (CK-MB) usually returns to normal levels within 2 to 3 days after a myocardial infarction, so it is unlikely to still be elevated 6 days later.

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An emergency department nurse is collecting information from a client who has stable vital signs when their other client begins to report chest pain. Which of the following should be the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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