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.

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Correct Answer is D

Explanation

Choice A reason: Completing an adverse occurrence report is important, but not the priority action. The nurse should first address the client's safety and potential complications from the medication error. This choice is incorrect.

Choice B reason: Obtaining blood for coagulation studies is necessary, but not the priority action. The nurse should first inform the healthcare provider of the error and the client's condition, and then follow the orders for laboratory tests and interventions. This choice is incorrect.

Choice C reason: Monitoring for signs of bleeding is essential, but not the priority action. The nurse should first notify the healthcare provider, who may prescribe antidotes or other treatments to reverse the effects of heparin and warfarin. This choice is incorrect.

Choice D reason: Notifying the healthcare provider is the priority action, as the client is at high risk of bleeding due to the interaction of heparin and warfarin¹. The healthcare provider can order appropriate measures to correct the coagulation status and prevent hemorrhage. This choice is correct.

A. Assume care of the client and assign the PN to the care of a different client. B. Acknowledge that the PN has positioned the client safely and correctly. C. Arrange for an unlicensed assistive personnel to assist the PN during the procedure. D. Demonstrate to the PN how to position the client more effectively for the procedure.

Correct Answer is D

Explanation

Choice A reason: Assuming care of the client and assigning the PN to the care of a different client is not the best action the nurse should take. This may undermine the PN's confidence and competence and create resentment and conflict.

Choice B reason: Acknowledging that the PN has positioned the client safely and correctly is not the best action the nurse should take. This may reinforce the incorrect positioning and lead to complications during the lumbar puncture.

Choice C reason: Arranging for an unlicensed assistive personnel to assist the PN during the procedure is not the best action the nurse should take. This may not address the root cause of the incorrect positioning and may not improve the PN's skills and knowledge.

Choice D reason: Demonstrating to the PN how to position the client more effectively for the procedure is the best action the nurse should take. This will correct the error and provide the PN with feedback and guidance on how to perform the task correctly in the future.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse reports that a client with a deep vein thrombosis (DVT) was mistakenly given heparin in addition to the prescribed warfarin. Which priority action should the nurse take?

Correct Answer is D

Explanation

The nurse observes a practical nurse (PN) placing a client on the right side with the left leg bent in preparation for a lumbar puncture. Which action should the nurse implement?

Correct Answer is D

Explanation

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?

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The home health aide caring for a homebound hospice client calls to inform the nurse that the client has reported feeling constipated. Which task should the nurse instruct the home health aide to perform?

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