The nurse obtains verbal prescriptions from the healthcare provider for an antianginal, telemetry, and STAT serum analysis for cardiac isoenzymes, after reading back the prescriptions to the healthcare provider of a client's upper gastric burning, left jaw pain, and nausea. Which intervention is most important for the nurse to implement?
Initiate telemetry and assess the client's cardiac rhythm.
Document description of nausea and administer the antiemetic.
Submit electronic prescriptions to the pharmacy and laboratory.
Obtain the client's 10-point score for radiating jaw pain.
The Correct Answer is A
Choice A reason: This is the most important intervention, as the client's symptoms suggest a possible myocardial infarction (MI) or angina. The nurse should initiate telemetry and assess the client's cardiac rhythm for any signs of ischemia, injury, or infarction. The nurse should also administer the antianginal medication as prescribed and monitor the client's response.
Choice B reason: This is a relevant intervention, as nausea is a common symptom of MI or angina, especially in women. The nurse should document the description of nausea and administer the antiemetic medication as prescribed. The nurse should also assess the client's abdominal pain and rule out other causes such as gastritis or ulcer.
Choice C reason: This is a necessary intervention, as the verbal prescriptions need to be submitted electronically to the pharmacy and laboratory for processing and verification. The nurse should also document the verbal prescriptions and the read-back process in the client's record. However, this is not the most important intervention, as it can be done after the client's condition is stabilized.
Choice D reason: This is not a priority intervention, as the client's jaw pain is likely related to the cardiac problem and not to a separate issue. The client's pain should be assessed using a standard scale such as the numeric rating scale or the Wong-Baker FACES scale. The nurse should also administer analgesics as prescribed and monitor the client's pain level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A child who has had a cold for two days and now is coughing up green sputum is not the most urgent client to assess. The child may have a bacterial infection that requires antibiotics, but the condition is not life-threatening or unstable. The child can be classified as urgent and seen within one hour.
Choice B reason: A male adolescent who has been vomiting for the past 12 hours and describes himself as very weak is not the most urgent client to assess. The adolescent may have dehydration, electrolyte imbalance, or gastroenteritis that requires fluid replacement and antiemetics, but the condition is not life-threatening or unstable. The adolescent can be classified as urgent and seen within one hour.
Choice C reason: A female client with severe right lower abdominal pain who is febrile and vomiting is the most urgent client to assess. The client may have appendicitis, ovarian torsion, ectopic pregnancy, or another serious condition that requires immediate diagnosis and treatment. The client is at risk of perforation, infection, shock, or hemorrhage and needs to be seen as soon as possible. The client can be classified as emergent and seen within 15 minutes.
Choice D reason: An elderly client with peripheral vascular disease who is complaining of severe leg pain when ambulating is not the most urgent client to assess. The client may have intermittent claudication, ischemia, or ulceration that requires analgesics, antiplatelets, or vascular surgery, but the condition is not life-threatening or unstable. The client can be classified as semi-urgent and seen within two hours.
Correct Answer is C
Explanation
Choice A reason: Nitroprusside sodium, an antihypertensive, is not the best medication infusion to assign to the PN. This medication requires close monitoring of blood pressure, heart rate, and cyanide levels. It also has a short half-life and needs frequent titration. These tasks are beyond the scope of practice of the PN and should be performed by the RN.
Choice B reason: Methotrexate, an antimetabolite chemotherapeutic agent, is not the best medication infusion to assign to the PN. This medication is used to treat various types of cancer and can cause severe side effects such as bone marrow suppression, hepatotoxicity, and mucositis. It also requires special precautions to prevent exposure and contamination. These tasks are beyond the scope of practice of the PN and should be performed by the RN.
Choice C reason: Octreotide acetate, an antidiarrheal agent, is the best medication infusion to assign to the PN. This medication is used to treat diarrhea caused by certain hormonal disorders such as carcinoid syndrome or acromegaly. It has a relatively long half-life and does not require frequent adjustments. It also has minimal side effects and does not need special precautions. These tasks are within the scope of practice of the PN and can be delegated by the RN.
Choice D reason: Amiodarone hydrochloride, an antiarrhythmic agent, is not the best medication infusion to assign to the PN. This medication is used to treat various types of cardiac arrhythmias and can cause serious side effects such as hypotension, bradycardia, pulmonary toxicity, and thyroid dysfunction. It also requires close monitoring of electrocardiogram, vital signs, and blood tests. These tasks are beyond the scope of practice of the PN and should be performed by the RN.
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