Family members bring a client to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data?

The symptoms indicate an acute coronary episode and should be treated as such.

The symptoms indicate angina and should be treated as such.

Treatment should be determined pending the results of an exercise stress test.

The symptoms indicate a pulmonary etiology rather than a cardiac etiology.

Answer and Explanation

The Correct Answer is A

A. The symptoms indicate an acute coronary episode and should be treated as such:

The client's symptoms, including sudden midsternal chest pain unrelieved with rest and a history of coronary artery disease (CAD), strongly suggest an acute coronary event, such as a myocardial infarction (heart attack). Pale, cool skin can also be indicative of decreased perfusion due to cardiac compromise. Given these critical signs and symptoms, the nurse should interpret this as a potential cardiac emergency and initiate immediate interventions aimed at managing and stabilizing the client's condition.

B. The symptoms indicate angina and should be treated as such:

While angina can present with symptoms such as chest pain, it is typically relieved with rest or nitroglycerin. In contrast, the client in this scenario has midsternal chest pain that is not relieved with rest, which is more indicative of an acute coronary event like a myocardial infarction. Therefore, interpreting the symptoms as angina and treating them as such may not be appropriate given the severity and persistence of the chest pain.

C. Treatment should be determined pending the results of an exercise stress test:

Waiting for the results of an exercise stress test is not appropriate in this scenario, as the client's presentation suggests an acute cardiac event that requires immediate intervention. Exercise stress tests are typically used for diagnostic purposes to assess cardiovascular function under controlled conditions but are not suitable for managing acute coronary episodes or emergencies.

D. The symptoms indicate a pulmonary etiology rather than a cardiac etiology:

While some symptoms, such as shortness of breath or chest pain, can overlap between cardiac and pulmonary conditions, the client's presentation with sudden midsternal chest pain unrelieved with rest, pale cool skin, and a history of CAD strongly suggests a cardiac etiology, specifically an acute coronary event. It is essential to prioritize cardiac assessment and intervention based on the client's symptoms and medical history.

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Correct Answer is D

Explanation

A. Take the iron with dairy products to enhance absorption: This statement is incorrect. Calcium-rich foods, such as dairy products, can inhibit iron absorption. It's recommended to take iron supplements with vitamin C-rich foods or beverages to enhance iron absorption.

B. Limit foods high in fiber due to the risk for diarrhea: While some individuals may experience gastrointestinal side effects such as constipation or diarrhea when taking iron supplements, it is not generally recommended to limit foods high in fiber. Adequate fiber intake is important for overall digestive health.

C. Increase the intake of vitamin E to enhance absorption: Vitamin E does not directly enhance iron absorption. Vitamin C is the nutrient that enhances iron absorption, so increasing intake of vitamin C-rich foods or taking vitamin C supplements along with iron supplements can improve iron absorption.

D. Iron will cause the stools to darken in color: This statement is correct. Iron supplements can cause stools to become dark or even black in color. This is a harmless side effect known as "iron stools" and is caused by the reaction of iron with substances in the digestive tract.

A. Notify the blood bank of the discrepancy B. Administer the blood as ordered. C. Complete an incident report. D. Contact the provider for further orders.

Correct Answer is B

Explanation

A. Notify the blood bank of the discrepancy:

This choice suggests that there is a discrepancy between the blood type of the unit on hand (type B) and the client's blood type (type AB). However, in reality, there is no discrepancy in this case because individuals with type AB blood are universal recipients and can receive blood from donors of any blood type, including type B. Therefore, there is no need to notify the blood bank of any discrepancy.

B. Administer the blood as ordered:

This choice is the correct action. Type AB individuals are known as universal recipients because they can safely receive blood from donors of any blood type (A, B, AB, or O) without causing a major transfusion reaction. Since the client has type AB blood and the unit of blood on hand is type B, the nurse can administer the blood as ordered without concerns about blood type compatibility.

C. Complete an incident report:

Completing an incident report is typically done when an unexpected event or error occurs during patient care. In this scenario, there is no error or unexpected event related to blood type compatibility, so there is no need to complete an incident report.

D. Contact the provider for further orders:

Contacting the provider for further orders would be necessary if there were a specific reason or concern related to the blood transfusion that requires clarification or additional instructions. However, in this case, there are no issues with blood type compatibility, so contacting the provider is not necessary.

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Family members bring a client to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data?

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Naxlex Comprehensive Predictor Exams

A nurse is providing education to a client with iron deficiency anemia who has been prescribed iron supplements. What should the nurse include in health education?

Correct Answer is D

Explanation

A nurse is preparing to administer blood to a client. The unit of blood on hand is type B, and the client has type AB blood. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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