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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

Rationale for Correct Choices

• Reye's syndrome: The toddler presents with acute onset of vomiting, lethargy, and altered mental status following a recent viral illness (influenza A). These are hallmark signs of Reye’s syndrome, a rare but serious condition causing hepatic and cerebral dysfunction in children.

• Aspirin administration: Use of aspirin during viral infections in children is strongly associated with the development of Reye’s syndrome. The guardians reported alternating aspirin with acetaminophen, directly increasing the toddler’s risk for this potentially life-threatening condition.

Rationale for Incorrect Choices

• Gastroenteritis: Gastroenteritis typically presents with diarrhea, abdominal cramping, and vomiting. While vomiting is present, the toddler also demonstrates lethargy and neurologic changes, which are not characteristic of routine gastroenteritis.

• Bronchitis: Bronchitis usually causes productive cough, wheezing, or respiratory distress. This toddler has a non-productive cough and clear lung sounds, making bronchitis an unlikely explanation for the current acute neurological and systemic symptoms.

• Oseltamivir administration: Oseltamivir is an antiviral used to treat influenza and is not associated with the development of Reye’s syndrome. The toddler’s severe symptoms are unrelated to this medication.

• Acetaminophen administration: Acetaminophen is generally safe in children at recommended doses. While it can cause liver toxicity in overdose, the scenario indicates appropriate use, making it an unlikely contributor to the toddler’s presentation.

A. Insert a rectal suppository. B. Assist the client to ambulate. C. Prepare the client for a paracentesis. D. Place the client in the prone position.

Correct Answer is B

Explanation

Rationale:
A. Insert a rectal suppository: While a suppository can relieve constipation, abdominal distention after laparoscopic surgery is often caused by retained gas from insufflation rather than stool, so this intervention may not be effective.

B. Assist the client to ambulate: Early ambulation promotes peristalsis and helps the body expel retained carbon dioxide gas from the abdomen, which is a common cause of post-laparoscopic distention. This is a safe and effective first-line intervention.

C. Prepare the client for a paracentesis: Paracentesis is used to remove fluid in cases of ascites, not routine post-surgical gas-related distention. It is unnecessary for uncomplicated laparoscopic procedures.

D. Place the client in the prone position: While repositioning may offer some comfort, it does not significantly facilitate the expulsion of gas or reduce abdominal distention. Ambulation is more effective.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a toddler in the outpatient setting. Exhibits Complete the following sentence by using the lists of options. The nurse recognizes the toddler has likely developed dropdown due to dropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

A nurse is caring for a client who had a laparoscopic cholecystectomy and is experiencing abdominal distention. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nursery nurse is attending the birth of a post-term infant. Exhibits Upon review of the medical record, the infant newborn is at risk for developing which of the following symptoms? Select all that apply

A nurse in an acute care facility is caring for a toddler. Exhibits For each assessment finding below, click to specify if the assessment finding is consistent with Crohn's disease, appendicitis, or intussusception. Each finding may support more than 1 disease process.

A nurse is assessing a 1-month-old infant at a pediatric office. Which of the following findings requires a referral for further care?

A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?

A nurse is planning to administer 2 units of packed RBCs to an older adult client who has anemia. Which of the following actions should the nurse plan to take? (Select all that apply.)

A nurse is reviewing the BUN result of a client who is taking cyclosporine following a kidney transplant. Which of the following laboratory studies should the nurse recognize as another renal function study that should be monitored?

A nurse is teaching a client who has multiple sclerosis. Which of the following instructions should the nurse include in the teaching?