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Exhibits

Click to highlight the findings that require follow up.

Neurological: Alert and oriented. Agitated. Denies headaches.

Cardiovascular: Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.

Respiratory: Rapid and shallow breaths. Clear breath sounds throughout bilateral lungs.

Gastrointestinal: Within normal limits (WNL).

Genitourinary: WNL

Musculoskeletal: WNL

Pain: 7 on a 0 to 10 scale, tightness and pressure in chest. Started approximately 2 hours ago and got progressively worse, unrelieved by rest.

Alert and oriented

chest pain described as pressure and tightness that is unrelieved with rest

Radial and pedal pulses 2+

Capillary refill 2 seconds

Rapid and shallow breaths

Clear breath sounds throughout bilateral lungs

7 on a 0 to 10 scale, tightness and pressure in chest

Answer and Explanation

The Correct Answer is ["B","E","G"]

Chest pain described as pressure and tightness that is unrelieved with rest: Chest pain that is described as tightness and pressure, particularly when unrelieved by rest, is a classic presentation of acute coronary syndrome (ACS), which includes conditions such as unstable angina or myocardial infarction (MI). This is a red flag symptom, as it indicates a need for immediate medical attention to rule out life-threatening conditions like MI, which can be fatal without timely intervention.

Rapid shallow breaths: Rapid and shallow breathing can be a response to acute pain, particularly in a situation involving cardiovascular stress. It may be indicative of the body's attempt to compensate for inadequate oxygenation due to cardiac ischemia, hypoxia, or anxiety.

Pain 7/10, tightness and pressure in the chest: A pain rating of 7/10 demands immediate evaluation and management, as it could indicate an evolving cardiovascular event. Moreover, tightness and pressure are specific descriptors of pain seen in ischemic heart disease, where there is reduced blood flow to the heart muscle, leading to discomfort due to oxygen deprivation.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A: Identifying effective pain relief measures is important but comes after determining the pain's characteristics. Without knowing the pain's quality, choosing the best pain relief strategy is challenging.

B: Observing body language and movement is valuable, but it does not provide specific details about the type of pain the client is experiencing.

C: A numeric pain scale measures the intensity of pain but does not assess the quality, which is important in cancer-related pain management.

D: Asking the client to describe the pain provides essential information about the quality (sharp, dull, throbbing, burning) and nature of the pain, allowing the nurse to better tailor pain management strategies.

A. Administer an antiemetic to prevent vomiting. B. Apply bilateral eye shields to reduce photosensitivity. C. Report the eye pain to the surgeon. D. Begin postoperative prophylactic antibiotics.

Correct Answer is C

Explanation

A. Administering an antiemetic is not the priority, as the pain reported by the client needs to be evaluated by the surgeon first.
B. While eye shields may be used to protect the eyes after surgery, the acute pain should be reported to the surgeon to rule out complications.
C. Acute, deep eye pain after laser trabeculoplasty could indicate complications, such as increased intraocular pressure, infection, or damage to the eye. Immediate reporting to the surgeon is necessary for further evaluation and intervention.
D. Prophylactic antibiotics may be prescribed postoperatively, but they are not the first response to acute pain.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with metastatic bone cancer is requesting pain medication. Which approach should the nurse use to assess the quality of the client's pain?

Correct Answer is D

Explanation

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. Which action should the nurse take?

Correct Answer is C

Explanation

Patient Data Exhibits Review H and P, nurse's notes, laboratory results, flow sheet, and prescriptions. Select the 3 findings that would require immediate action from the nurse while the laboring mother is receiving an epidural anesthesia.

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A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?

Patient Data Exhibits The nurse reviews the prescriptions and plans initial steps for caring for the client. Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response option selected.

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The nurse knows that a medication has the side effect of orthostatic hypotension. Which assessment should the nurse make before administering the medication?

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?