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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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Choice A rationale

Group discussions can be beneficial for sharing experiences and learning from others, but they do not provide the hands-on, practical experience that is characteristic of the psychomotor learning domain.

Choice B rationale

-answer meetings can be useful for clarifying doubts and enhancing understanding, but they do not offer the opportunity for physical manipulation of objects or execution of procedures, which is central to psychomotor learning.

Choice C rationale

Practice sessions can be an effective method for psychomotor learning as they allow for repeated performance of a skill. However, in the context of teaching adolescents with newly placed ostomies, role play might be more beneficial as it allows for the simulation of real-life scenarios and the practice of problem-solving skills in a safe and controlled environment.

Choice D rationale

Role play is a method that falls under the psychomotor domain of learning. It involves acting out scenarios and provides an opportunity for hands-on practice and learning. In the context of adolescents with newly placed ostomies, role play can help them practice self-care tasks related to ostomy management in a safe and supportive environment.

A. Inject 5 units of air into the bottle of regular insulin. B. Withdraw the correct dose of NPH insulin from the bottle. C. Inject 10 units of air into the bottle of NPH insulin. D. Withdraw the correct dose of regular insulin from the bottle.

Correct Answer is C,A,D,B

Explanation

Choice A rationale

Injecting 5 units of air into the bottle of regular insulin is the second step in the procedure. This is done after injecting air into the NPH insulin bottle. The purpose of this step is to pressurize the vial, making it easier to withdraw the insulin.

Choice B rationale

Withdrawing the correct dose of NPH insulin from the bottle is the last step in the procedure. This is done after withdrawing the regular insulin to prevent contamination of the regular insulin with the NPH insulin.

Choice C rationale

Injecting 10 units of air into the bottle of NPH insulin is the first step in the procedure. This is done before injecting air into the regular insulin bottle. The purpose of this step is to pressurize the vial, making it easier to withdraw the insulin.

Choice D rationale

Withdrawing the correct dose of regular insulin from the bottle is the third step in the procedure. This is done after injecting air into the regular insulin bottle and before withdrawing the NPH insulin. The purpose of this step is to ensure that the correct dose of regular insulin is administered.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning a teaching session for a group of adolescents who each recently had an ostomy surgically placed. Which of the following methods should the nurse use as a psychomotor approach to learning?

Correct Answer is D

Explanation

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to be mixed together and administered subcutaneously. Determine the correct order of steps for this procedure.

Correct Answer is C,A,D,B

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is instructing a client whose left leg is in a cast on how to use crutches. Which statement from the client indicates they have understood the instructions?

The client was admitted with a productive cough with thick yellow sputum.Breath sounds with crackles were heard in the left upper lobe and decreased breath sounds at bases bilaterally. What is the client’s temperature?

A nurse is examining a patient’s medication prescription which states, “digoxin 0.25 by mouth daily.”. Which component of the prescription should the nurse confirm with the healthcare provider?

A nurse is giving a change-of-shift report about a client they admitted earlier that day who has pneumonia. Which piece of information is the priority for the nurse to provide?

A nurse is providing care for a patient who has terminal liver cancer.Which statement from the patient should the nurse recognize as a sign of spiritual distress?

A nurse is assessing an older adult client’s risk for falls.Which assessments should the nurse use to identify the client’s safety needs? (Select all that apply)

A nurse is preparing to transfer a patient who can bear weight on one leg from the bed to a chair. After securing a safe environment, what should the nurse do next?