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. Mottled skin: Mottling is typically a late sign of poor perfusion or approaching death and does not indicate pain. It reflects circulatory changes rather than discomfort requiring analgesia.
B. Constricted pupils: Constricted pupils may result from certain medications or neurological changes, but they are not a reliable indicator of pain. Pupillary changes alone do not guide pain management.
C. Restlessness: Restlessness is a common manifestation of pain in clients receiving palliative care, especially when verbal communication is limited. Administering prescribed pain medication can help alleviate discomfort and improve comfort.
D. Cheyne-Stokes respirations: This irregular breathing pattern occurs in advanced illness or near end-of-life and is not an indicator of pain. It reflects neurological or metabolic changes rather than discomfort requiring analgesia.
Correct Answer is C
Explanation
Rationale:
A. "Placement of the catheter is confirmed by a CT scan.": Catheter placement is not routinely confirmed by CT scan. Instead, correct placement of a central venous catheter is verified by a chest X-ray immediately after insertion to ensure proper tip location.
B. "You will be under general anesthesia for this procedure.": General anesthesia is not required for placement of a nontunneled percutaneous central venous catheter. The procedure is typically performed using local anesthesia and aseptic technique at the bedside.
C. "The provider will wear a mask while performing the procedure.": The provider wears a mask, sterile gown, gloves, and cap as part of strict sterile technique during insertion to prevent catheter-related bloodstream infections.
D. "Your head will be elevated as high as possible while the catheter is inserted.": The client’s head is not elevated during insertion. Instead, a flat or slight Trendelenburg position is used to distend neck veins and reduce the risk of air embolism.
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