An emergency department nurse triages clients who present with chest discomfort. Which client would the nurse plan to assess first?
Client who describes intense squeezing pressure across the chest.
Client who reports moderate pain that is worse on inspiration.
Client who reports cramping substernal pain.
Client who describes pain as a dull ache.
The Correct Answer is A
A. This description is indicative of possible myocardial infarction (MI), a life-threatening emergency. Immediate evaluation and intervention, such as administering oxygen, obtaining an EKG, and providing pain relief, are crucial to prevent further damage to the heart and reduce mortality.
B. Moderate pain worse on inspiration suggests pleuritic pain, often associated with conditions like pleuritis or pulmonary embolism, which are serious but generally not as immediately life-threatening as an MI.
C. Cramping substernal pain may indicate a gastrointestinal issue, such as gastroesophageal reflux disease (GERD), which is less urgent than a potential MI.
D. A dull ache may be related to musculoskeletal or gastrointestinal issues and does not suggest the immediate need for intervention seen in MI.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Although monitoring hemodynamic parameters is important, this option does not address the immediate issue of low preload, as indicated by the low CVP and PAWP, suggesting hypovolemia.
B. Furosemide is a diuretic and would further decrease intravascular volume, which is inappropriate given the signs of hypovolemia.
C. Decreasing IV fluids would exacerbate the low preload and worsen the client's condition by reducing intravascular volume even further.
D. Administering 0.9% Normal Saline @ 150 mL/hr is the most appropriate intervention. The low CVP and PAWP indicate hypovolemia, and increasing fluid administration will help to increase the preload, thereby improving the client's hemodynamic status.
Correct Answer is B
Explanation
A. A stable client with chronic angina is not in immediate danger, and the scheduled dose of nifedipine is not an urgent priority.
B. The client with unstable angina who has just undergone a heart catheterization with balloon angioplasty requires immediate assessment for complications such as bleeding, clot formation, or re-occlusion of the artery.
C. The 65-year-old post-MI client is stable, and while their anxiety is important to address, it is not an immediate concern compared to other clients.
D. The client post-coronary artery bypass with a potassium level of 4.2 mEq/L is stable and does not require urgent intervention.
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