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.
Have the client stop walking and sit down.
Administer sublingual nitroglycerin to the client.
Measure the client's vital signs.
The Correct Answer is B
Rationale:
A. Obtain a 12-lead ECG for the client: An ECG is important for diagnosing myocardial ischemia or infarction, but it is not the immediate first step. The priority is to stop activity and reduce myocardial oxygen demand before further diagnostics.
B. Have the client stop walking and sit down: Angina is often triggered by physical exertion. Stopping activity and sitting down reduces oxygen demand on the heart, alleviates symptoms, and prevents further ischemia. This is the most immediate and essential first action.
C. Administer sublingual nitroglycerin to the client: Nitroglycerin helps relieve anginal pain by dilating coronary arteries, but it should be given after the client has stopped activity and rested. Administering it while the client is still active may not be effective or safe.
D. Measure the client's vital signs: While vital signs are important for assessing the client’s current status, the priority is to stop exertion, which is likely contributing to myocardial oxygen imbalance. Assessment follows immediate symptom relief measures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Use a loud tone of voice when speaking with the client: Clients with visual impairments do not necessarily have hearing loss. Speaking loudly is unnecessary and may be perceived as disrespectful or startling. Clear, calm, and descriptive communication is more appropriate.
B. Rearrange client’s bedside table items frequently: Frequently moving personal items creates confusion and increases the risk of accidents or frustration for a visually impaired client. Consistent item placement enhances safety and independence.
C. Guide the client by walking parallel with them: Walking parallel without physical or verbal guidance may not be helpful. It’s more effective to offer the client your arm so they can follow your movement and safely navigate their surroundings.
D. Remove objects from client's path to the bathroom: Clearing obstacles from the client's walking path reduces the risk of tripping and falls. This is a key safety intervention for clients with reduced visual sensory perception and promotes independent, safe mobility.
Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"D"}
Explanation
Rationale for Correct Choices
- Intravenous antibiotics: The client presents with uterine tenderness, dark foul-smelling lochia, a mildly elevated temperature, and an elevated WBC count, all of which point to endometritis, a common postpartum infection. The first-line treatment for endometritis is broad-spectrum IV antibiotics to prevent complications like sepsis.
- Increase in daily fluid intake: Infection and fever can increase fluid loss through insensible means, and fluids support circulation, renal function, and antibiotic delivery. Encouraging increased fluid intake also helps address dehydration from fever and supports healing and lactation.
Rationale for Incorrect Choices
- Kleihauer-Betke test: This test detects fetal-to-maternal hemorrhage and is used in trauma or suspected placental abruption in Rh-negative mothers. There is no indication of bleeding or Rh incompatibility in this case, so it is not appropriate here.
- Tocolytic medication: Tocolytics are used to suppress uterine contractions in preterm labor. This client is postpartum and has no signs of preterm labor or uterine hyperstimulation, so this medication is not warranted.
- Intrauterine tamponade balloon: This device is used for severe postpartum hemorrhage due to uterine atony that doesn’t respond to medical treatment. The client has moderate lochia but no signs of active hemorrhage or hemodynamic instability, so it is not indicated.
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