The nurse enters her client’s room and finds the client complaining pf dyspnea, chest pain and syncope. The nurse assesses the client and notes the following findings. The client is pale and diaphoretic with a blood pressure of 90/60mmHg and respirations of 33. The client is anxious and fearing death. Which action should the nurse take first?

Administer oxygen via nasal cannula

Administer prescribed pain medications

Administer NS IV fluid

Ask the provider for a dopamine prescription

Answer and Explanation

The Correct Answer is A

A. Administer oxygen via nasal cannula: The client's symptoms of dyspnea, chest pain, syncope, and hypotension suggest a possible acute cardiovascular event, such as a myocardial infarction (MI) or pulmonary embolism (PE). Administering oxygen should be the priority to improve oxygenation and prevent hypoxia, which could exacerbate the client's symptoms and further compromise cardiac function.

B. Administer prescribed pain medications. Pain relief may be necessary, but stabilizing oxygen levels is the priority.

C. Administer NS IV fluid. Fluid administration may be helpful, but oxygenation is more critical in this situation to address the potential underlying respiratory or cardiac issue.

D. Ask the provider for a dopamine prescription. While dopamine may be used in cases of shock, the immediate action should be to ensure the client is adequately oxygenated.

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Correct Answer is A

Explanation

A. Document the finding and continue to monitor the client: A PR interval of 0.24 seconds indicates first-degree AV block, which is often asymptomatic and benign if vital signs are stable. No immediate intervention is required other than continued monitoring.

B. Prepare the client for temporary pacemaker insertion: Pacemakers are not indicated for asymptomatic first-degree AV block.

C. Notify the health care provider immediately and then administer epinephrine IV: This is unnecessary as the client is stable and shows no signs of hemodynamic compromise.

D. Administer atropine per agency bradycardia protocol and then notify the health care provider: Atropine is not required for a stable heart rate of 72 bpm.

A. Maintain hyperventilation to a PaCO2 of 15 to 20mm Hg. B. Routinely suction to prevent accumulation of respiratory secretions C. Encourage visitation to prevent feelings of isolation. D. Avoid positioning the client with neck and hip flexion.

Correct Answer is D

Explanation

A. Maintain hyperventilation to a PaCO2 of 15 to 20 mm Hg. Hyperventilation can reduce ICP by causing vasoconstriction of cerebral blood vessels; however, a PaCO2 as low as 15–20 mmHg may lead to excessive vasoconstriction, reducing cerebral blood flow and causing cerebral ischemia. A PaCO2 target closer to 30–35 mmHg is typically recommended, and even this is used cautiously.

B. Routinely suction to prevent accumulation of respiratory secretions. Suctioning can increase ICP due to stimulation of the cough reflex. It should be performed only as needed and in a way that minimizes stimulation, such as preoxygenation and limiting suction duration.

C. Encourage visitation to prevent feelings of isolation. While social support is important, minimizing environmental stimuli (including limiting visitation) is crucial for clients with increased ICP to prevent overstimulation and further increases in ICP.

D. Avoid positioning the client with neck and hip flexion. Maintaining proper alignment of the head and neck is essential to promote venous drainage and reduce intracranial pressure (ICP). Flexion of the neck or hips can impede venous outflow, exacerbate ICP, and compromise cerebral perfusion.

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Naxlex Comprehensive Predictor Exams

The nurse is evaluating a cardiac monitor strip for their client that displays a sinus rhythm with a heart rate of 72 bpm. The PR interval is 0.24 seconds. The vital signs are stable and the client reports no symptoms. What is the most appropriate nursing intervention?

Correct Answer is A

Explanation

A nurse is caring for client with increased intracranial pressure What is an appropriate nursing intervention for the client?

Correct Answer is D

Explanation

A client with new onset right-sided weakness is admitted to the emergency department and the following orders are received. Which order should the nurse implement first?

The nurse is assigned to the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first?

The nurse is teaching a group of staff nurses about myocarditis. What would the nurse identify as being potential risk factors for this condition? Select All That Apply

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The nurse has received a change-of-shift report on the following clients. Which client should the nurse see first?

The charge nurse observes a new graduate nurse who is caring for a client who has a severe head injury. Which action by the new graduate nurse requires the charge nurse to intervene?