The nurse is caring for a client with a history of coronary artery disease who reports waking up with a sudden onset of vise-like chest pressure.

The client reports that the pain decreases at rest but continues to feel a constant mid-chest pressure. What intervention should the nurse perform in the immediate management of the client?

What intervention should the nurse perform in the immediate management of the client?

Determine the presence of ST-elevations or non-ST-elevations on the electrocardiogram

Initiate dim lighting, lower alarm volumes, and control traffic in and out of the room area

Verify troponin level assessments are scheduled every 3-6 hours for a series of three

Apply oxygen via nasal cannula and titrate to keep oxygen saturation above 93%

Answer and Explanation

The Correct Answer is D

Choice A rationale
Determining the presence of ST-elevations or non-ST-elevations on the electrocardiogram is an important step in diagnosing a myocardial infarction. However, this is typically performed by a healthcare provider or a trained technician, not a nurse.
Choice B rationale
While creating a calm and quiet environment can be beneficial for a client experiencing chest pain, it is not the immediate intervention that should be performed. The client’s symptoms suggest a possible cardiac event, which requires immediate medical intervention.
Choice C rationale
Verifying that troponin level assessments are scheduled every 3-6 hours for a series of three is important for diagnosing myocardial infarction. However, this is not the immediate intervention that should be performed. The client’s symptoms suggest a possible cardiac event, which requires immediate medical intervention.
Choice D rationale
Applying oxygen via nasal cannula and titrating to keep oxygen saturation above 93% is the correct intervention. This action helps to increase the oxygen supply to the myocardium, potentially decreasing the extent of myocardial damage and relieving chest pain.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale
While obtaining a serum drug screen might be helpful in confirming the presence of benzodiazepines or other substances, it is not the most immediate concern in a client experiencing severe agitation and tremors due to withdrawal.
Choice B rationale
Naloxone is an opioid antagonist and would not be effective in managing withdrawal symptoms from benzodiazepines.
Choice C rationale
Seizure precautions should be initiated as withdrawal from benzodiazepines can lead to severe withdrawal symptoms, including seizures. Therefore, ensuring the safety of the client by initiating seizure precautions is the best initial nursing action.
Choice D rationale

While education is an important part of nursing care, in this situation, the client’s immediate physical needs take precedence.

A. Reduced level of pain B. Improved visual acuity C. Full volume of pedal pulses D. Granulating tissue in foot ulcer . .

Correct Answer is A

Explanation

Choice A rationale
Pregabalin is a medication used to treat nerve pain, particularly in conditions like diabetic peripheral neuropathy. A reduced level of pain would indicate that the medication is effective.
Choice B rationale
Improved visual acuity is not a typical outcome of pregabalin treatment for diabetic peripheral neuropathy. Pregabalin does not typically affect vision.
Choice C rationale
Full volume of pedal pulses is not a typical outcome of pregabalin treatment for diabetic peripheral neuropathy. Pregabalin does not typically affect circulation.
Choice D rationale
Granulating tissue in a foot ulcer is not a typical outcome of pregabalin treatment for diabetic peripheral neuropathy. Pregabalin does not typically affect wound healing.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is experiencing severe agitation and tremors due to withdrawal from the benzodiazepine alprazolam. What is the best initial nursing action?

Correct Answer is C

Explanation

A patient with diabetic peripheral neuropathy has been taking pregabalin for the past four days. Which finding would indicate to the nurse that the medication is effective?

Correct Answer is A

Explanation

A nurse is preparing a 50 mL dose of 50% dextrose IV for a patient experiencing insulin shock. What is the best method for administering the medication?

A client with a venous ulcer, which has not responded to intravenous vancomycin treatment and is discharging pus, has been admitted with a potential infection of Vancomycin-Resistant Enterococci (VRE). Which nursing interventions should be included in the care plan? Select all that apply.

What is the most crucial nursing intervention to include in the care plan for a patient who is 12 hours post- thyroidectomy?

The nurse is preparing a client with breast cancer for BRCA1 and BRCA2 genetic testing. Which pathophysiological process should the nurse use to support client teaching?

A client who weighs 176 pounds is prescribed enoxaparin sodium 1.5 mg/kg/day subcutaneously. The medication is available in a 120 mg/0.8 mL prefilled syringe. How many mL should the nurse administer? (Enter numerical value only.)