Scenario:

A 45-year-old female client is admitted to the emergency department with complaints of sudden shortness of breath and chest tightness. She has a history of hypertension and diabetes.

Exhibits

A nurse is assessing the client at 0700 hrs. Which of the following actions should the nurse take first? A Initiate a cardiac enzyme panel

Initiate a cardiac enzyme panel

Start intravenous fluid therapy

Provide pain relief medication

Obtain an electrocardiogram (ECG)

Perform a comprehensive physical assessment

Answer and Explanation

The Correct Answer is D

Choice A rationale: Initiating a cardiac enzyme panel can help determine if the client has had a heart attack. However, this is not the immediate priority. The client’s symptoms suggest a possible cardiac event, which needs to be addressed first. An ECG can provide immediate information, while a cardiac enzyme panel takes longer to return results.

Choice B rationale: Starting intravenous fluid therapy may be necessary depending on the client’s hydration status and overall condition. However, it is not the immediate priority. The client’s symptoms suggest a possible cardiac event, which needs to be addressed first.

Choice C rationale: Providing pain relief medication may be necessary if the client is in pain. However, the client’s primary complaint is chest tightness and difficulty breathing, not pain. Therefore, addressing the potential cardiac issue is the priority.

Choice D rationale: The client’s symptoms of sudden shortness of breath, chest tightness, and anxiety, along with her history of hypertension and diabetes, are concerning for a possible cardiac event. An electrocardiogram (ECG) can provide immediate information about the heart’s electrical activity and help identify if the client is experiencing a heart attack or other cardiac event. This should be the first action taken to quickly identify the cause of the client’s symptoms and initiate appropriate treatment.

Choice E rationale: Performing a comprehensive physical assessment is an important part of nursing care. However, in this situation, the client’s symptoms indicate a need for immediate intervention to address her potential cardiac issue.

Choice F rationale: Monitoring the client’s blood glucose levels is important given her history of diabetes. However, this is not the immediate priority. The client’s symptoms suggest a possible cardiac event, which needs to be addressed first.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale

Using an extension cord to watch television in the living room does not indicate effective learning about using a walker. Extension cords can create a tripping hazard, which is particularly dangerous for someone using a walker.

Choice B rationale

Hiring someone to trim the tree that overhangs the front porch stairs indicates an understanding of the need to remove potential obstacles that could interfere with the safe use of the walker.

Choice C rationale

Placing the alarm clock on the bedroom dresser does not demonstrate an understanding of how to use a walker safely. It does not address any of the key safety considerations associated with walker use.

Choice D rationale

Replacing the old throw rug in the kitchen with a new one does not necessarily indicate effective learning about using a walker. Throw rugs can be a tripping hazard for individuals using a walker, regardless of whether they are old or new.

A. “I feel a dull ache in my stomach.”. B. “I notice that the pain intensifies after I eat.”. C. “The pain is causing me to feel nauseous.”. D. “I’m experiencing mild pain.”.

Correct Answer is A

Explanation

The quality of pain is a subjective description of what the pain feels like to the patient. The statement “I feel a dull ache in my stomach” provides a description of the quality of the patient’s pain.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge instructions to a patient who will be using a walker.Which of the following statements by the patient indicates that the teaching has been effective?

Correct Answer is B

Explanation

A nurse is attending to a patient who is experiencing discomfort. Which of the following patient statements should the nurse document in the initial pain assessment to describe the quality of the patient’s pain?

Correct Answer is A

Explanation

A nurse is educating a client who is under protective isolation precautions. Which statement from the client indicates they have understood the teaching?

A nurse is educating an older adult client at risk for osteoporosis on starting a regular physical activity program. Which type of activity should the nurse recommend?

A nurse is performing a skin assessment for a client who expresses concern about skin cancer.Which of the following findings should the nurse identify as a potential indication of a skin malignancy?

A nurse is caring for a patient who is receiving fluids through a peripheral IV catheter. Which of the following observations at the IV site should the nurse identify as signs of infiltration?

A nurse is about to administer an injection of an opioid medication to a patient. The nurse has drawn 1 mL of the medication from a 2 mL vial.What should the nurse do next?

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse.Which of the following actions should the nurse include?