A nurse is assisting in the care of a client who has a pulmonary embolism and is experiencing dyspnea. Which of the following actions should the nurse take first?

Place the client in high-Fowler's position.

Obtain the client's vital signs.

Administer heparin to the client.

Encourage the client to cough and deep breathe.

Answer and Explanation

The Correct Answer is A

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Correct Answer is C

Explanation

A bladder infection can lead to confusion or other changes in mental status, especially in older adults. A normal temperature and WBC count do not necessarily indicate a bladder infection. Diminished reflexes are not typically associated with a bladder infection.

A: A temperature of 37.3° C (99.1° F) is within the normal range and does not necessarily indicate a bladder infection.

B: A WBC count of 9,000/mm3 is within the normal range and does not necessarily indicate a bladder infection.

D: Diminished reflexes are not typically associated with a bladder infection.

A. "I will take four nitroglycerin sublingual tablets if I have chest pain." B. "I will have hot, dry, and flushed skin if I am having a heart attack." C. "I will wait 30 minutes before taking action if I have heartburn." D. "I will notify emergency response if I have sudden jaw pain."

Correct Answer is D

Explanation

This response indicates that the client understands that sudden jaw pain can be a sign of a heart attack and requires immediate medical attention.

A. "I will take four nitroglycerin sublingual tablets if I have chest pain." This is an incorrect statement because taking four nitroglycerin sublingual tablets can lead to hypotension and can be life-threatening.

B. "I will have hot, dry, and flushed skin if I am having a heart attack." This is an incorrect statement because hot, dry, and flushed skin is not a typical sign of a heart attack.

C. "I will wait 30 minutes before taking action if I have heartburn." This is an incorrect statement because heartburn is not a symptom of angina and waiting 30 minutes to take action can lead to further complications.

Explanation: The client with angina should be educated about the signs and symptoms of a heart attack and when to seek medical attention. Jaw pain is one of the signs of a heart attack, and the client should seek emergency medical attention immediately.

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A nurse is assisting in the care of a client who has a pulmonary embolism and is experiencing dyspnea. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

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