A nurse is assisting with the care of a client in the emergency department who reports severe radiating chest pain and shortness of breath. The client appears restless, frightened, and slightly cyanotic. The provider prescribes oxygen by nasal cannula at 4 L/min stat, cardiac enzyme levels, IV fluids, and a 12-lead ECG. Which of the following actions should the nurse take first?

Attach the leads for a 12-lead ECG.

Obtain a blood sample.

Initiate oxygen therapy.

Insert the IV catheter.

Answer and Explanation

The Correct Answer is C

Choice A reason: While attaching leads for a 12-lead ECG is important, it is not the most immediate action required for a client showing signs of distress and potential hypoxia.

Choice B reason: Obtaining a blood sample is necessary for diagnosing the cause of chest pain but is not the first priority in an emergency situation.

Choice C reason: Initiating oxygen therapy is the first and most critical step in managing a client with severe chest pain, shortness of breath, and cyanosis to ensure adequate oxygenation.

Choice D reason: Inserting an IV catheter is important for administering medications and fluids but comes after ensuring the client is receiving sufficient oxygen.

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Correct Answer is C

Explanation

Choice A Reason:Thrombolytic agents (clot-dissolving drugs) are indeed used to dissolve blood clots that block coronary artery flow during a heart attack. These medications help restore blood flow and prevent further damage to the heart muscle.

Choice B Reason:Bedrest is commonly recommended after a myocardial infarction (heart attack) to reduce the workload on the heart. It allows the heart to heal and minimizes strain during the recovery phase.

Choice C Reason:Timely diagnosis of myocardial infarction is crucial because early intervention can significantly impact the extent of muscle damage. Rapid treatment helps preserve heart tissue and prevent complications.

Choice D Reason:Percutaneous coronary intervention (PCI) involves using a stent to reopen a blocked coronary artery. This procedure restores blood flow and improves outcomes for patients with myocardial infarction.

A. "Pills disintegrate when touched." B. "Pills no longer cause a tingling sensation when used." C. "Pills smell like vinegar." D. "Pills become discolored."

Correct Answer is C

Explanation

Choice A reason: While disintegration indicates a pill is no longer stable, it is not specific to nitroglycerin tablets.

Choice B reason: The absence of a tingling sensation may not necessarily indicate that nitroglycerin tablets need to be replaced, as this sensation can vary.

Choice C reason: Nitroglycerin tablets should be replaced if they smell like vinegar, as this indicates that the medication may have degraded and may not be effective.

Choice D reason: Discoloration can occur due to various reasons and does not specifically indicate that nitroglycerin tablets have lost potency.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement regarding the treatment of a myocardial infarction is incorrect?

Correct Answer is C

Explanation

Which of the following statements by a patient demonstrates to the nurse that the patient understands when to replace prescribed nitroglycerin tablets?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who has a new diagnosis of angina pectoris. Which of the following information about anginal pain should the nurse include in the teaching?

Which of the following is not true about depression?

The nurse is caring for a group of patients. Which patient is at the highest risk for developing heart failure (HF)?

Your new patient is taking an MAOI for severe depression. What would you tell the dietary department about her upcoming meals?

The nurse who is assessing a patient with major depression would expect to observe which of the following symptoms?

A nurse is evaluating the outcomes for a client who has depression following the death of his wife 3 months ago. Which of the following client statements indicates a need for further intervention?

Ms. S is admitted to your medical unit with a diagnosis of dehydration and a history of depression. She tells you, "I just can't eat, I'm not hungry." What would be your best therapeutic response?