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 D

Explanation

Choice A rationale

This choice represents the ethical principle of autonomy, which respects the client’s rights and preferences in their healthcare decisions.

Choice B rationale

This choice demonstrates the ethical principle of fidelity, which involves keeping promises and commitments, such as honoring a DNR order.

Choice C rationale

This choice reflects the ethical principle of beneficence, which involves taking positive actions to help others and promote the well-being of clients.

Choice D rationale

This choice represents the ethical principle of veracity, which involves truth-telling. In this situation, the nurse is being truthful to the client about their cancer diagnosis, thus demonstrating veracity.

A. Determine the reasons why the client is refusing to use the incentive spirometer. B. Document the client’s refusal to participate in health restorative activities. C. Administer a pain medication to the client.

Correct Answer is A

Explanation

The nurse’s priority action should be to determine the reasons why the client is refusing to use the incentive spirometer. Understanding the client’s concerns or fears can help the nurse address them and encourage the client to participate in this important aspect of postoperative care.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients on a medical-surgical unit.In which situation does the nurse demonstrate the ethical principle of veracity?

Correct Answer is D

Explanation

A postoperative client refuses to use an incentive spirometer following major abdominal surgery. What is the nurse’s priority action?

Correct Answer is A

Explanation

A nurse is administering fluids to a client.Which of the following assessments should the nurse identify as the priority when monitoring for adverse effects?

A home health nurse is conducting an admission assessment of an elderly patient who has their caregiver present. Which observation should the nurse identify as a potential sign of elder abuse?

A client expresses anger when the nurse does not respond within 5 minutes of ringing for the nurse. Which response by the nurse is appropriate?

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 preparing to insert a peripheral IV catheter for an older adult client. Which action should the nurse plan to take?

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?

The client’s chest x-ray shows lung hyperinflation and left upper lobe pneumonia. What is the most likely diagnosis?

A nurse is assessing a patient’s ability to use a walking cane.Which of the following observations would indicate that the patient is using the cane correctly?