The nurse is caring for a client in the ED just arriving with severe chest pain, shortness of breath, diaphoresis, and jugular distention. What will be the most important thing the nurse will do within the first 10 minutes?

Administer aspirin

12 Lead Electrocardiography

Assess vital signs

Administer morphine

Answer and Explanation

The Correct Answer is B

A. Administer aspirin:

Aspirin is commonly given to patients suspected of having a heart attack because it helps to inhibit platelet aggregation and reduce the risk of further clot formation. However, the administration of aspirin typically follows the confirmation of a cardiac event through diagnostic tests like the ECG. Aspirin is not the initial priority compared to obtaining diagnostic data.

B. 12 Lead Electrocardiography (ECG):

This is the most critical and time-sensitive action because it helps to quickly assess the patient's cardiac status. A 12 Lead ECG can identify important findings such as ST-segment elevation or depression, which are indicative of acute myocardial infarction (heart attack) or other cardiac abnormalities. Early detection and intervention are crucial in improving outcomes for patients with suspected cardiac events.

C. Assess vital signs:

Vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, provide valuable information about the patient's overall condition and can help determine the severity of the cardiac event. While assessing vital signs is important, performing the ECG takes precedence due to its immediate relevance in diagnosing and managing a potential cardiac emergency.

D. Administer morphine:

Morphine may be indicated for pain relief in patients with acute coronary syndromes. However, its administration should be based on the patient's pain level, hemodynamic stability, and other factors assessed after obtaining the ECG and vital signs. Morphine administration is not the primary action within the first 10 minutes of the patient's arrival; it follows the initial assessment and diagnostic procedures.

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Correct Answer is D

Explanation

A. The pain can be severe and sudden at rest: This statement is more characteristic of unstable angina, where chest pain can occur at rest or with minimal exertion and is often severe and unpredictable.

B. The pain persists with rest and organic nitrates: This statement is more indicative of unstable angina or variant (Prinzmetal's) angina. Stable angina typically improves with rest and nitroglycerin (an organic nitrate).

C. The pain usually lasts longer than 20 minutes: Stable angina pain typically lasts for a few minutes (usually less than 5 to 10 minutes) and resolves with rest or nitroglycerin. Pain lasting longer than 20 minutes may indicate an acute coronary syndrome such as unstable angina or myocardial infarction.

D. Exertion and anxiety can trigger the pain: This statement is accurate for stable angina. Exertion, such as physical activity or emotional stress, can trigger anginal pain in individuals with stable angina due to increased oxygen demand by the heart.

Correct Answer is ["0.8"]

Explanation

To calculate the volume of heparin to administer subcutaneously, you can use the following formula:

Volume (mL) = Desired dose (units) / Concentration (units/mL)

In this case:

Desired dose = 3,800 units

Concentration = 5,000 units/mL

Volume (mL) = 3,800 units / 5,000 units/mL ≈ 0.76 mL

Rounded to the nearest tenth, the nurse should administer approximately 0.8 mL of heparin subcutaneously daily.

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The nurse is caring for a client in the ED just arriving with severe chest pain, shortness of breath, diaphoresis, and jugular distention. What will be the most important thing the nurse will do within the first 10 minutes?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching for a client who has a new diagnosis of stable angina pectoris. The nurse should give the client which of the following information about anginal pain?

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving heparin 3,800 units subcutaneously daily. Available is heparin 5,000 units/mL. How many mL should the nurse administer? Round to thenearesttenth

Correct Answer is ["0.8"]

Explanation

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