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.
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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E","F"]
Explanation
Choice A rationale: Implementing airborne precautions is not necessary in this case. The client’s symptoms and the progression of their condition suggest a severe respiratory infection, possibly pneumonia, but there is no indication that the infection is airborne.
Airborne precautions are typically reserved for diseases that are spread through tiny droplets in the air, such as tuberculosis, measles, or chickenpox.
Choice B rationale: The client’s worsening respiratory distress, evidenced by increased shortness of breath, use of accessory muscles for breathing, decreased oxygen saturation, and changes in sputum, indicate that the client may require intubation and mechanical ventilation. This would ensure that the client’s airway remains open and that they receive adequate oxygen.
Choice C rationale: The client has a history of well-managed diabetes mellitus. Given the stress of the illness and the initiation of corticosteroid therapy (which can raise blood glucose levels), it would be important to monitor the client’s blood glucose levels frequently.
Choice D rationale: The client has been prescribed Levofloxacin, an antibiotic, which should be administered as prescribed. Given the client’s symptoms and the progression of their condition, it is likely that they have a bacterial infection. Antibiotics are critical for treating bacterial infections.
Choice E rationale: Ensuring strict hand hygiene before and after client contact is a standard precaution in all healthcare settings to prevent the spread of infection.
Choice F rationale: Increasing fluid intake can help thin out the sputum, making it easier for the client to cough it up. This can help improve the client’s respiratory function.
Choice G rationale: There is no current indication for a chest tube insertion. While the client’s chest X-ray shows extensive consolidation and possible pleural effusion, the notes do not indicate that the effusion is large enough to require drainage at this time. A chest tube would be considered if the effusion was large and causing significant respiratory distress, which is not clearly the case here.
Correct Answer is A
Explanation
Choice A rationale
Pressing gently on the tragus of the ear after administering the medication can help the medication to reach the inner ear.
Choice B rationale
Packing a small piece of cotton deep into the patient’s ear canal is not recommended as it can cause damage to the ear.
Choice C rationale
Moving the patient’s auricle down and back towards their head is not necessary when administering otic medication.
Choice D rationale
Tilting the patient’s head backward for 5 minutes is not required when administering otic medication.
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