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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Correct Answer is B

Explanation

Choice A rationale

The route of administration, “by mouth”, is clearly stated in the prescription. Therefore, there is no need to confirm this with the healthcare provider.

Choice B rationale

The dosage of the medication, “0.25”, is not specified in terms of units (e.g., milligrams, micrograms). This could lead to errors in medication administration. Therefore, the nurse should confirm the dosage of the medication with the healthcare provider.

Choice C rationale

The frequency of administration, “daily”, is clearly stated in the prescription. Therefore, there is no need to confirm this with the healthcare provider.

Choice D rationale

The name of the medication, “digoxin”, is clearly stated in the prescription. Therefore, there is no need to confirm this with the healthcare provider.

A. Granulation tissue covers the wound bed. B. Slight erythema at wound edges. C. The surrounding tissue is warm to touch. D. The patient reports pain as a 2 on a scale from 0 to 10. .

Correct Answer is A

Explanation

Choice A rationale

Granulation tissue covering the wound bed is a positive sign of wound healing. Granulation tissue is a key component of the wound healing process, typically forming during the proliferation phase. It consists of new connective tissue and tiny blood vessels that develop in the wound bed as part of the body’s response to injury. Therefore, the presence of granulation tissue covering the wound bed indicates an improvement in the patient’s condition.

Choice B rationale

Slight erythema at the wound edges could be a sign of inflammation or infection. Erythema, or redness of the skin, is often associated with inflammation or infection. While it can be a normal part of the healing process, persistent or increasing erythema could indicate a problem such as infection or irritation. Therefore, slight erythema at the wound edges does not necessarily indicate an improvement in the patient’s condition.

Choice C rationale

The surrounding tissue being warm to touch could be a sign of inflammation or infection. When skin feels hot to the touch, it often means that the body’s temperature is hotter than normal. This can happen due to an infection or an illness, but it can also be caused by an

environmental situation that increases body temperature. Therefore, the surrounding tissue being warm to touch does not necessarily indicate an improvement in the patient’s condition.

Choice D rationale

The patient reporting pain as a 2 on a scale from 0 to 10 could indicate that the patient’s pain is minor. On a pain scale, a score of 2 usually indicates minor pain. However, pain is a subjective experience and can vary greatly among individuals. Therefore, while a lower pain score generally suggests less severe pain, it does not necessarily indicate an improvement in the patient’s overall condition.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

A nurse is providing discharge instructions to a patient who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the patient and their family? (Select all that apply.)

A nurse is educating a terminally ill patient about declining resuscitation in a living will.The patient asks, “What would happen if I arrived at the emergency department and I had difficulty breathing?” Which of the following responses should the nurse make?

A nurse in a clinic is caring for a middle-aged patient who states, “The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening.What does that involve?” Which of the following responses should the nurse make?

A patient reports abdominal pain.An abdominal x-ray indicates a large amount of fecal material throughout the colon, but no evidence of gastrointestinal obstruction is observed.Which of the following actions should the nurse take?

A nurse is preparing to suction secretions from a patient who has a new tracheostomy. Which of the following actions should the nurse plan to take?

A nurse responds to a call light and finds a patient lying on the bathroom floor. What should the nurse do first?

A nurse is administering an otic medication to an older adult patient.Which of the following actions should the nurse take to ensure the medication reaches the inner ear?