A client was admitted 2 days ago with pneumonia. The client is now having chest pain. Vital signs are Temperature 37.2 C (98.9 F), Pulse 108, Blood pressure 160/90, respirator rate 24, and Oxygen Saturation 90%. What should the nurse do first?

Call another nurse for help

Give pain medication as ordered

Call the admitting healthcare provider

Tell client to remain calm

Apply oxygen via nasal cannula as ordered

Answer and Explanation

The Correct Answer is E

A. Calling another nurse for help is unnecessary unless additional assistance is required after initial interventions.
B. Giving pain medication as ordered may address the chest pain but does not address the immediate need for oxygenation.
C. Calling the admitting healthcare provider can be done later if symptoms do not improve, but the immediate priority is to improve oxygenation.
D. Telling the client to remain calm may help reduce anxiety but does not address the low oxygen saturation.
E. Applying oxygen via nasal cannula as ordered is the priority action to improve the client’s oxygen saturation and alleviate hypoxemia, which could be contributing to their chest pain.

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Correct Answer is E

Explanation

A. Palpate, inspect, percuss, and then auscultate is not the correct order, as inspection is always performed first.
B. Percuss, palpate, auscultate, and then inspect is incorrect, as inspection should come first.
C. Auscultate, inspect, percuss, and then palpate is also incorrect, as auscultation is typically the last step.
D. Inspect, auscultate, palpate, and then percuss is close but does not follow the standard order.
E. Inspect, palpate, percuss, then auscultate is the correct order for respiratory assessment, allowing for a thorough and systematic approach.

A. immobility B. smoking C. history of stomach ulcers D. overhydration E. taking birth control pills

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

Explanation

A. Immobility is a significant risk factor for venous thromboembolism (VTE) since prolonged inactivity can lead to stasis of blood flow, increasing clot formation risk.
B. Smoking contributes to hypercoagulability and vascular damage, both of which elevate the risk of clot formation in veins.
C. A history of stomach ulcers is not directly associated with an increased risk of blood clots; rather, it pertains more to gastrointestinal health.
D. Overhydration generally does not increase the risk of blood clots; rather, maintaining adequate hydration is important for circulation.
E. Taking birth control pills can increase the risk of blood clots due to hormonal changes that promote hypercoagulability.

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A client was admitted 2 days ago with pneumonia. The client is now having chest pain. Vital signs are Temperature 37.2 C (98.9 F), Pulse 108, Blood pressure 160/90, respirator rate 24, and Oxygen Saturation 90%. What should the nurse do first?

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Naxlex Comprehensive Predictor Exams

Which statement by the nurse indicates the correct order of steps to take when performing a focused assessment of the respiratory system?

Correct Answer is E

Explanation

The nurse is reviewing the risk factors for a blood clot in a vein. Which of these situations can put a client at higher risk for developing a blood clot in a vein? Select all that apply.

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

Explanation

When performing a respiratory assessment on a patient, the nurse notices a costal vertebral angle (CVA) of approximately 160 degrees. How would finding?

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The nurse is on the medical/surgical floor is getting a new admission. The client is being admitted for shortness of breath (dyspnea). Which assessment finding would be of concern?

A client was admitted 2 days ago with pneumonia. The client is now having chest pain. Vital signs are Temperature 37.2 C (98.9 F), Pulse 108, Blood pressure 160/90, respirator rate 24, and Oxygen Saturation 90%. What should the nurse do first?

When assessing a newly admitted client, the nurse notes a thrill along the left sternal border. To obtain more information about the cause of the thrill, which action will the nurse take next?

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