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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: 30 mL of serous fluid from a compression bulb device is not a cause for concern. It indicates that the wound is healing and the device is functioning properly.

Choice B reason: 40 mL per hour of dark, cloudy urine from a urinary catheter may indicate dehydration, infection, or hematuria, but it is not an immediate priority. The nurse should monitor the urine output and characteristics, and report any abnormal findings to the provider.

Choice C reason: 20 mL of serosanguinous drainage from a chest tube is expected after thoracic surgery. It reflects the normal inflammatory response and the removal of excess fluid from the pleural space.

Choice D reason: No observable drainage from a 3-day-old Penrose drain is a sign of possible obstruction or infection. The nurse should assess the site for swelling, redness, pain, or purulent drainage, and notify the provider immediately. The Penrose drain should be replaced or removed as soon as possible.

A. Place an isolation cart outside of the room to initiate droplet precautions. B. Schedule bedside play time with the occupational therapist. C. Instruct the child's parents about the need for transmission precautions. D. Assign the child to a room close to the nurse's station.

Correct Answer is A

Explanation

Choice A reason: Mumps is a highly contagious viral infection that spreads through respiratory droplets¹. Droplet precautions are necessary to prevent the transmission of the virus to other patients and staff. An isolation cart contains personal protective equipment (PPE) such as masks, gloves, and gowns that the nurse and visitors should wear when entering the room.

Choice B reason: Scheduling bedside play time with the occupational therapist may be beneficial for the child's development and well-being, but it is not the most important intervention. The child may be too sick or uncomfortable to engage in play activities, and the therapist may be exposed to the virus.

Choice C reason: Instructing the child's parents about the need for transmission precautions is an important intervention, but it is not the first one. The nurse should first ensure that the child is isolated and protected from spreading the infection, and then educate the parents about the signs, symptoms, and complications of mumps, as well as the preventive measures such as vaccination and hygiene.

Choice D reason: Assigning the child to a room close to the nurse's station may facilitate the monitoring and care of the child, but it is not the most important intervention. The child may be disturbed by the noise and activity near the station, and the risk of transmission may increase if the child is not isolated.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning care for four postoperative clients, each with a different drainage system. Which information, received in report, requires immediate follow-up intervention by the nurse?

Correct Answer is D

Explanation

A 5-year-old boy with mumps is being transferred to the pediatric unit. Which nursing intervention is most important for the nurse to implement?

Correct Answer is A

Explanation

Four clients are scheduled to receive IV infusions, but there are only three intravenous (IV) pumps available. Which prescribed infusion can most safely be administered without an IV infusion pump?

The healthcare provider prescribes an oral medication to be given daily for 3 days. However, the medication was also given on the fourth day. Which intervention is most important for the charge nurse to implement?

A child is admitted to the pediatric unit after being diagnosed with pertussis. The nurse observes an unlicensed assistive personnel (UAP) donning a pair of gloves before entering the room to give the child a popsicle. Which action should the nurse take?

Several family members are visiting a client who had a myocardial infarction 4 days ago. The unlicensed assistive personnel (UAP) informs the nurse that one of the visitors is lying on the client's bed. Which action should the nurse implement?

A group of nurse managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization's budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment?

When making assignments for residents of a long-term care facility who require assistance with feeding, which client should the charge nurse assign to the practical nurse (PN) rather than the unlicensed assistive personnel (UAP)?

In assigning client care to a nurse and a practical nurse (PN), it is most important to assign which client to the nurse?