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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

Inability to locate the dorsalis pedis pulse and increasing pain are signs of compromised circulation, requiring immediate intervention.

Choice B rationale

Pain relieved by medication does not indicate an urgent situation and suggests effective pain management.

Choice C rationale

Generalized weakness and increased sensitivity to touch are not typically indicative of a critical emergency requiring immediate reporting.

Choice D rationale

Localized edema and discoloration are expected findings following a fracture and do not necessitate immediate reporting.

A. Give the insulin when the breakfast tray arrives. B. Give the insulin at 07:00. C. Give the insulin at 07:30. D. Give the insulin 30 minutes after breakfast with the client's other routine medicines.

Correct Answer is C

Explanation

Choice A rationale

Administering insulin when the breakfast tray arrives may not provide sufficient time for the insulin to take effect before the client begins eating, potentially leading to hyperglycemia.

Choice B rationale

Administering insulin at 07: is too early and may result in hypoglycemia before the client eats breakfast.

Choice C rationale

Administering insulin at 07: allows sufficient time for the insulin to take effect before the client eats breakfast, helping to maintain appropriate blood glucose levels.

Choice D rationale

Administering insulin 30 minutes after breakfast is too late and could result in hyperglycemia since the client would have already consumed carbohydrates.

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A client one (1) day postoperative for coronary artery bypass graft (CABG) reports chest pain.Which intervention should the nurse implement first?

Nursing Test Bank

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A client one (1) day postoperative for coronary artery bypass graft (CABG) reports chest pain.
Which intervention should the nurse implement first?