A nurse is caring for a client who has angina and reports a feeling of heaviness in the chest while ambulating in the hall. Which of the following actions should the nurse take first?
Obtain a 12-lead ECG for the client.
Administer sublingual nitroglycerin to the client.
Measure the client's vital signs.
Have the client stop walking and sit down.
The Correct Answer is D
Rationale:
A. Obtain a 12-lead ECG for the client: An ECG is important to assess for myocardial ischemia or infarction, but it should be done after immediate measures are taken to reduce myocardial oxygen demand.
B. Administer sublingual nitroglycerin to the client: Nitroglycerin helps relieve chest pain by dilating coronary arteries, but it should be given only after the client is safely seated or resting to prevent hypotension or injury.
C. Measure the client's vital signs: Vital signs provide valuable baseline data, but addressing the client’s immediate safety and reducing cardiac workload takes priority.
D. Have the client stop walking and sit down: Stopping activity decreases oxygen demand on the heart and prevents worsening ischemia or collapse, making it the first and most critical action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Tends to be very expressive with gestures and body language: Chinese cultural norms often value modesty and restrained expression rather than overt gestures. Expecting expressive behavior may not align with typical postpartum practices.
B. Prefers to make direct eye contact with health care personnel: In many Chinese cultural contexts, avoiding direct eye contact is a sign of respect, especially toward authority figures, rather than a preference for direct engagement.
C. Prefers foods that maintain a balance of hot and cold within the body: Traditional Chinese postpartum practices emphasize restoring balance through diet, often using “hot” and “cold” foods to support recovery and prevent illness, making this a key consideration in care planning.
D. Expresses pain freely and loudly: Cultural norms often encourage quiet endurance of pain, especially postpartum, rather than vocal or exaggerated expressions of discomfort.
Correct Answer is D
Explanation
Rationale:
A. Instruct the client’s partner to assume care of the colostomy for the client: Having the partner take over care may reinforce the client’s avoidance and hinder acceptance of the stoma. The goal is to promote gradual involvement and self-care.
B. Encourage the client and partner to avoid expressing negative feelings about the colostomy: Suppressing emotions can delay psychological adjustment. The nurse should instead encourage open discussion of feelings.
C. Transfer the client to a rehabilitation facility for instruction about self-management of the colostomy: Transferring the client is unnecessary at this stage and may add emotional stress. Education and emotional support can be effectively provided in the current care setting.
D. Suggest the client join a support group for people who have colostomies: Support groups provide opportunities to share experiences with others who have undergone similar surgeries. Peer support can reduce isolation, promote acceptance, and help the client adapt to lifestyle changes more confidently.
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