A client is admitted to the hospital with chest pain and shortness of breath. The nurse obtains a history and performs a physical examination.
Which of the following information should the nurse report to the provider immediately?
The client has a history of hypertension and diabetes mellitus.
The client takes aspirin 81 mg daily and metformin 500 mg twice daily.
The client's blood pressure is 180/100 mm Hg and heart rate is 110 beats/min.
The client's chest pain radiates to the left arm and is relieved by nitroglycerin.
The Correct Answer is C
The client's blood pressure is 180/100 mm Hg and heart rate is 110 beats/min.
Rationale: The nurse should report the client's blood pressure and heart rate to the provider immediately, as these are signs of hypertensive crisis and tachycardia, which can indicate a serious cardiovascular complication, such as myocardial infarction, stroke, or heart failure.
Incorrect options:
A) The client has a history of hypertension and diabetes mellitus. - This is an important information to obtain from the client, as it indicates risk factors for cardiovascular disease. However, this is not an urgent finding that requires immediate reporting to the provider, as it does not reflect the client's current condition or acuity.
B) The client takes aspirin 81 mg daily and metformin 500 mg twice daily. - This is an important information to obtain from the client, as it indicates the medications that the client is taking for their chronic conditions. However, this is not an urgent finding that requires immediate reporting to the provider, as it does not reflect any adverse effects or interactions of these medications.
D) The client's chest pain radiates to the left arm and is relieved by nitroglycerin. - This is an important information to obtain from the client, as it indicates that the client has angina pectoris, which is chest pain caused by reduced blood flow to the heart muscle. However, this is not an urgent finding that requires immediate reporting to the provider, as it shows that the chest pain is stable and responsive to nitroglycerin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The presence and quality of pedal pulses on both legs.
Rationale: The nurse should obtain information on the presence and quality of pedal pulses on both legs from the report, as this indicates the adequacy of blood circulation and perfusion to the lower extremities, which can be compromised by surgery, positioning, or complications such as thromboembolism or compartment syndrome.
Incorrect options:
A) The type and size of the prosthesis used may be important information for the surgical team and the client's medical record, but it is not immediately relevant to the immediate post-operative care provided by the nurse.
B) The amount and color of urine output during surgery is not directly related to the client's condition after a total hip arthroplasty and is not the primary focus of the nurse's assessment at this time.
C) The type and dose of anesthesia administered is important information for the client's medical record and may have implications for post-operative care, but it is not the most critical information for the nurse to obtain immediately upon receiving the report.
Correct Answer is B
Explanation
Check the tubing for any leaks or kinks.
Rationale: The nurse should check the tubing for any leaks or kinks, as continuous bubbling in the water seal chamber indicates an air leak in the system, which can impair lung re-expansion and drainage. The nurse should locate and seal the leak, and notify the provider if necessary.
Incorrect options:
A) Clamp the chest tube near the insertion site. - This is an incorrect action, as clamping the chest tube can cause a tension pneumothorax, which is a life-threatening condition that occurs when air accumulates in the pleural space and compresses the lung and other structures. The nurse should only clamp the chest tube briefly when changing the drainage system or assessing for an air leak.
C) Increase the suction pressure to the drainage system. - This is an incorrect action, as increasing the suction pressure to the drainage system can cause damage to the lung tissue and increase the risk of infection. The nurse should follow
the provider's prescription and the manufacturer's guidelines for setting and adjusting the suction pressure.
D) Document the finding as an expected outcome. - This is an incorrect action, as documenting the finding as an expected outcome implies that continuous bubbling in the water seal chamber is normal, which it is not. The nurse should document
the finding as an abnormal finding and report it to the provider.
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