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A client with a history of myocardial infarction is experiencing chest pain. Which intervention should the nurse implement first?
- A. Administer oxygen therapy as prescribed.
- B. Administer aspirin as prescribed.
- C. Administer nitroglycerin sublingually as prescribed.
- D. Obtain an electrocardiogram (ECG).
Correct Answer: A
Rationale: Administering oxygen therapy is the initial priority in managing chest pain in a client with a history of myocardial infarction. Oxygen therapy helps improve oxygenation, which is crucial in reducing myocardial damage. While administering aspirin and nitroglycerin are essential interventions in the treatment of myocardial infarction, oxygen therapy takes precedence because it addresses the immediate need for oxygen supply to the heart muscle. Obtaining an ECG is important but can be done after ensuring adequate oxygenation.
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A 65-year-old male client with a history of smoking and high cholesterol is admitted with shortness of breath and chest pain. Which diagnostic test should the nurse anticipate preparing the client for first?
- A. Electrocardiogram (ECG)
- B. Chest X-ray
- C. Arterial blood gases (ABGs)
- D. Pulmonary function tests (PFTs)
Correct Answer: A
Rationale: The correct answer is an Electrocardiogram (ECG). An ECG should be performed first to assess for cardiac ischemia, especially given the client's symptoms and history. Chest X-ray (Choice B) may be ordered to evaluate the lungs but would not be the initial test for this client presenting with chest pain and shortness of breath. Arterial blood gases (ABGs) (Choice C) are used to assess oxygenation and acid-base balance but are not the primary diagnostic test for a client with suspected cardiac issues. Pulmonary function tests (PFTs) (Choice D) are used to assess lung function and would not be the first test indicated in this scenario.
A client with diabetes mellitus is admitted with a blood glucose level of 640 mg/dl and is unresponsive. Which intervention should the nurse implement first?
- A. Administer 50% dextrose IV push
- B. Administer IV fluids as prescribed
- C. Check the client's blood glucose level
- D. Prepare the client for immediate dialysis
Correct Answer: B
Rationale: Administering IV fluids as prescribed is the priority intervention in a client with a blood glucose level of 640 mg/dl and unresponsiveness. Severe hyperglycemia can lead to dehydration and electrolyte imbalances, and administering IV fluids can help manage hyperglycemia and prevent further complications. Administering dextrose IV push (Choice A) can exacerbate hyperglycemia in this scenario. Checking the client's blood glucose level (Choice C) is important but not the immediate priority when the client is unresponsive. Immediate dialysis (Choice D) is not indicated as the first intervention for hyperglycemia.
A client with cirrhosis is admitted with jaundice and ascites. Which laboratory value requires immediate intervention?
- A. Serum albumin of 3.0 g/dL
- B. Serum bilirubin of 3.0 mg/dL
- C. Serum ammonia level of 80 mcg/dL
- D. Serum sodium level of 135 mEq/L
Correct Answer: C
Rationale: A serum ammonia level of 80 mcg/dL is most concerning in a client with cirrhosis as it may indicate hepatic encephalopathy, requiring immediate intervention. High serum ammonia levels can lead to altered mental status, confusion, and even coma. Serum albumin (choice A) is often decreased in cirrhosis but does not require immediate intervention. Serum bilirubin (choice B) elevation is expected in cirrhosis and may not require immediate intervention unless very high. Serum sodium (choice D) within the given range is generally acceptable and does not require immediate intervention.
A client with a history of chronic kidney disease (CKD) is scheduled for a CT scan with contrast. Which laboratory value should the nurse review before the procedure?
- A. Serum creatinine
- B. Blood urea nitrogen (BUN)
- C. Serum potassium
- D. Serum glucose
Correct Answer: A
Rationale: The correct answer is A: Serum creatinine. Before a CT scan with contrast, the nurse should review the serum creatinine level. This is crucial in patients with CKD because contrast agents can potentially worsen kidney function and lead to contrast-induced nephropathy. Monitoring serum creatinine helps assess kidney function and determine the risk of complications. Choices B, C, and D are less relevant in this scenario. Blood urea nitrogen (BUN) is another marker of kidney function, but serum creatinine is a more specific indicator. Serum potassium levels are important in assessing electrolyte balance but are not directly related to the risk of contrast-induced nephropathy. Serum glucose levels are not typically a primary concern before a CT scan with contrast in a patient with CKD.
A client who is receiving long-term steroid therapy complains of blurred vision. Which intervention should the nurse implement first?
- A. Instruct the client to use artificial tears to lubricate the eyes
- B. Administer an ophthalmic antibiotic as prescribed
- C. Arrange for the client to see an optometrist for an eye exam
- D. Notify the healthcare provider immediately
Correct Answer: D
Rationale: The correct answer is to notify the healthcare provider immediately (Option D). Blurred vision in a client on long-term steroid therapy can be a sign of serious conditions like cataracts or glaucoma, which need urgent medical evaluation and management. Instructing the client to use artificial tears (Option A) may help with dry eyes but does not address the underlying cause of blurred vision. Administering an ophthalmic antibiotic (Option B) is not indicated unless there is a specific infection present. Referring the client to an optometrist for an eye exam (Option C) may delay necessary medical intervention by the healthcare provider, who should be involved promptly in this situation.