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 A

Explanation

A. Pulmonary crackles/rales: Left-sided heart failure leads to a buildup of fluid in the lungs, causing pulmonary congestion and crackles/rales on auscultation.

B. Weight gain: This is more commonly associated with right-sided heart failure due to fluid retention, though it can be seen in both types of heart failure.

C. Hepatomegaly: Hepatomegaly is typically associated with right-sided heart failure due to congestion in the systemic circulation.

D. Jugular vein distention: JVD is a sign of right-sided heart failure, as it indicates increased central venous pressure.

A. Reoccurrence of chest pain/discomfort B. Puncture site for bleeding/hematoma C. pulse distal to puncture site D. urinary output

Correct Answer is ["A","B","C"]

Explanation

A. Reoccurrence of chest pain/discomfort: This can indicate restenosis or complications post-PCI, requiring immediate attention.

B. Puncture site for bleeding/hematoma: Bleeding at the puncture site is a common complication, so it must be closely monitored.

C. Pulse distal to puncture site: Checking the pulse distal to the puncture site helps assess for arterial occlusion or compromised blood flow, which can occur if a hematoma or clot forms.

D. Urinary output: While monitoring urinary output is important for overall assessment, it is not directly related to complications specific to PCI.

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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

Which of the following is an indication of Left sided heart failure?

Correct Answer is A

Explanation

Which of the following should the nurse assess in a patient who has just undergone a PCI (percutaneous coronary intervention) (select all that apply)

Correct Answer is ["A","B","C"]

Explanation

Which of the following is not a cause of high-output heart failure?

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