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 C

Explanation

A. "I will not have to get an IV placed."An IV may be placed in some cases, especially if the stress test includes the use of a pharmacological agent (like adenosine or dobutamine) in place of exercise.

B. "I can eat my breakfast before the test."Clients are typically instructed to fast for at least 3 hours before the exercise stress test. Eating could interfere with accurate test results and the ability to safely exercise. The client should not eat right before the test.

C. "I must not drink my hot chocolate in the morning."Caffeine can interfere with the results of the exercise stress test by increasing heart rate and potentially masking abnormal responses to exercise. Therefore, the client should avoid caffeine (including hot chocolate) before the test.

D. "I can wear the clothes I would wear to the office."The client should wear comfortable clothing and shoes that allow for physical activity and movement, such as athletic wear. Office attire may not be suitable for the physical exertion required during the exercise stress test.

A. Anxiety B. Sleep C. Fever D. Hyperglycemia E. Blood loss

Correct Answer is ["A","C","E"]

Explanation

A. Anxiety:

Anxiety can lead to an increased heart rate due to the activation of the sympathetic nervous system. When a person is anxious, their body releases stress hormones like adrenaline, which can stimulate the heart to beat faster. This increased sympathetic activity can cause sinus tachycardia, where the heart rate is faster than normal.

B. Sleep:

While sleep can affect heart rate variability, causing fluctuations in heart rate during different stages of sleep, it typically does not cause a significant and sustained increase in heart rate like sinus tachycardia. Sleep is more likely to influence heart rate patterns rather than directly cause sinus tachycardia.

C. Fever:

Fever, especially in response to infection or inflammation, can lead to an elevated heart rate. The body's response to fever includes increased metabolic activity, which can raise the heart rate as part of the physiological stress response. Fever-induced sinus tachycardia is a common finding in individuals with infections.

D. Hyperglycemia:

While hyperglycemia (high blood sugar levels) can have cardiovascular effects over time, such as contributing to atherosclerosis and heart disease, it is not typically a direct cause of sinus tachycardia. Sinus tachycardia is more commonly associated with acute stressors like anxiety, fever, or hypovolemia (such as from blood loss).

E. Blood loss:

Significant blood loss, such as during surgery or due to trauma, can result in hypovolemia, where there is a decrease in blood volume circulating in the body. In response to hypovolemia, compensatory mechanisms kick in, including an increase in heart rate (sinus tachycardia), to maintain blood pressure and perfusion to vital organs.

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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

The nurse has given education for a client who is going to have an exercise stress test. The nurse knows the client understands the teaching when they say what?

Correct Answer is C

Explanation

The nurse receives a client from the post-anesthesia unit with a new onset of sinus tachycardia and a heart rate of 118 beats per minute. To which reasons does the nurse relate the increased heart rate? (Select All that Apply.)

Correct Answer is ["A","C","E"]

Explanation

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