What action would be most helpful to the nurse in determining whether the chest pain of a patient who has just entered the emergency department is cardiac in origin?

Performing a 12-lead ECG

Administering NTG to see if the pain goes away

Gathering a complete medical history

Asking the patient if performing a Valsalva maneuver reduces the pain

Answer and Explanation

The Correct Answer is A

A. Performing a 12-lead ECG: An ECG is the most definitive and immediate tool to determine if chest pain is cardiac in origin, as it can detect ischemic changes, arrhythmias, or other cardiac abnormalities.

B. Administering NTG to see if the pain goes away: While nitroglycerin (NTG) may relieve ischemic chest pain, it is not definitive for diagnosing the pain's origin and should not be the first step without further assessment.

C. Gathering a complete medical history: Although a medical history is important, it will not immediately determine if the pain is cardiac in origin.

D. Asking the patient if performing a Valsalva maneuver reduces the pain: The Valsalva maneuver is not a reliable method to differentiate cardiac from non-cardiac chest pain and could potentially worsen certain conditions.

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Correct Answer is C

Explanation

A. Partially compensated Metabolic Alkalosis: This is incorrect because the pH is within normal limits (7.35-7.45), and the elevated PaCO2 and bicarbonate suggest a respiratory issue rather than a metabolic one.

B. Fully compensated Metabolic Acidosis: This is incorrect because the primary disturbance is respiratory, not metabolic. A compensated metabolic acidosis would typically show a low PaCO2 as compensation.

C. Fully compensated Respiratory Acidosis: Correct. The pH is within the normal range, indicating full compensation. The elevated PaCO2 and bicarbonate reflect a chronic respiratory acidosis that has been compensated by the kidneys.

D. Partially compensated Respiratory Alkalosis: This is incorrect because in respiratory alkalosis, the PaCO2 would be low, not high.

A. Monitoring of results of liver function testing B. Assessment for signs and symptoms of jaundice C. Measurement of abdominal girth and body weight D. Assessment for variceal bleeding

Correct Answer is C

Explanation

A. Monitoring of results of liver function testing: While important, monitoring liver function tests is a routine assessment rather than a prioritized one compared to assessing for complications like ascites.

B. Assessment for signs and symptoms of jaundice: Jaundice is a common finding in cirrhosis but does not necessarily indicate an acute complication.

C. Measurement of abdominal girth and body weight: In advanced cirrhosis, monitoring for ascites and fluid retention is critical as these indicate worsening disease and potential complications.

D. Assessment for variceal bleeding: Incorrect. While important, the priority in routine assessment is monitoring for ascites and fluid overload, which can be managed more readily.

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What action would be most helpful to the nurse in determining whether the chest pain of a patient who has just entered the emergency department is cardiac in origin?

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Naxlex Comprehensive Predictor Exams

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