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 {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}
Explanation
Rationale:
- Encourage the client to discuss their feelings: Encouraging emotional expression is a key therapeutic approach in managing bulimia nervosa. It allows the client to explore underlying psychological issues, such as anxiety and fear of weight gain, which often contribute to disordered eating behaviors.
- Provide a reduced sodium diet: Sodium restriction is not indicated in this client. In fact, the client has a slightly low sodium level (134 mEq/L), and further restriction could worsen electrolyte imbalances, which are already contributing to cardiac instability.
- Request a prescription for fluoxetine: Fluoxetine, an SSRI, is approved for the treatment of bulimia nervosa and can reduce the frequency of binge-purge episodes. It is also effective in treating coexisting anxiety or depressive symptoms, which are common in this population.
- Request a prescription for bupropion: Bupropion is contraindicated in clients with eating disorders due to its seizure risk. In clients with bulimia, frequent vomiting and low electrolytes increase this risk significantly, making bupropion an inappropriate choice.
- Monitor daily intake and output: Monitoring intake and output helps evaluate hydration status and kidney function, both of which may be compromised due to chronic purging. It also helps track nutritional rehabilitation and prevent complications from electrolyte shifts.
Correct Answer is C
Explanation
Rationale:
A. "You should avoid vaginal spermicides while breastfeeding.": Vaginal spermicides are generally considered safe during breastfeeding. They do not contain hormones and do not affect milk production, so avoidance is not typically necessary unless the client has specific contraindications.
B. "The lactation amenorrhea method is effective for your first year postpartum.": This method is only effective during the first 6 months postpartum, provided the mother is exclusively breastfeeding and menstruation has not resumed. Beyond that period, the risk of ovulation increases and it becomes unreliable.
C. "Place the transdermal birth control patch on your upper outer arm.": The patch can be applied to several sites, including the upper outer arm, abdomen, buttock, or upper torso. This is an appropriate instruction and part of standard patient teaching for transdermal contraceptive use.
D. "You can continue to use the diaphragm you used before your pregnancy.": The diaphragm often requires refitting postpartum due to changes in vaginal tone and cervix position. Using the same diaphragm without evaluation could reduce effectiveness and increase risk of unintended pregnancy.
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