A client one (1) day postoperative for coronary artery bypass graft (CABG) reports chest pain.
Which intervention should the nurse implement first?
Notify the healthcare provider.
Assess the client's vital signs and check the telemetry monitor.
Encourage the client to take deep breaths.
Administer pain medication immediately.
The Correct Answer is B
Choice A rationale
Notifying the healthcare provider is necessary, but assessing the client's condition comes first to provide relevant information.
Choice B rationale
Assessing the client's vital signs and telemetry monitor is the first step to determine the cause of chest pain and ensure it is not due to a life-threatening issue such as myocardial infarction.
Choice C rationale
Encouraging the client to take deep breaths can be helpful but is not the first priority. It addresses pain related to breathing but not the underlying cause.
Choice D rationale
Administering pain medication is important, but only after determining the cause of the chest pain and ruling out serious complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A decreased white blood cell count indicates the body's response to infection is improving, showing the effectiveness of the antibiotics.
Choice B rationale
Increased chest pain and shortness of breath would suggest worsening of the condition, not improvement.
Choice C rationale
Adventitious breath sounds and increased cough are signs that pneumonia may be persisting or worsening.
Choice D rationale
Improved appetite and weight gain are positive signs but are not direct indicators of the effectiveness of antibiotic treatment.
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale
Serum creatinine is assessed annually to evaluate kidney function, as diabetes can lead to nephropathy and renal impairment.
Choice B rationale
Urine for microalbuminuria is important to detect early kidney damage, which can occur in diabetic nephropathy.
Choice C rationale
Hearing (audio) exam is not a standard annual test for diabetic complications. Diabetes primarily affects the vascular system, kidneys, and nerves.
Choice D rationale
Chest x-ray is not routinely performed annually for diabetes management. It is used when there are specific indications such as respiratory symptoms.
Choice E rationale
Monofilament testing of the foot is conducted annually to detect diabetic neuropathy and prevent foot ulcers and infections.
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