A nurse is caring for a client who suddenly develops chest pain and dyspnea. Which of the following actions should the nurse take first
Place the client on bedrest.
Obtain the client's ABG levels.
Elevate the head of the client's bed.
Prepare the client for a ventilation-perfusion scan
The Correct Answer is C
A. Place the client on bedrest: While limiting the client’s activity is important to reduce oxygen demand, it is not the first priority. Immediate actions should focus on improving oxygenation and reducing respiratory distress.
B. Obtain the client's ABG levels: Although obtaining arterial blood gases provides valuable information about oxygenation and acid-base balance, it does not address the immediate need to relieve the client's breathing difficulty and hypoxia.
C. Elevate the head of the client's bed: Elevating the head of the bed promotes lung expansion and improves oxygenation, making it the first action to reduce dyspnea and ease the client’s breathing. It is a simple, quick intervention that can stabilize the client while further assessments are conducted.
D. Prepare the client for a ventilation-perfusion scan: A V/Q scan may be indicated to diagnose conditions like pulmonary embolism, but it is a diagnostic step that follows stabilization. Immediate efforts must first focus on ensuring adequate oxygenation and respiratory support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Smoking in bed: Smoking in bed is a major fire hazard and one of the leading causes of residential fires. Falling asleep with a lit cigarette can easily ignite bedding, mattresses, or upholstered furniture, leading to fast-spreading, deadly fires. This behavior significantly increases the risk of injury or death from residential fires.
B. Leaving the stove on: Leaving the stove unattended can also cause kitchen fires, but cooking-related incidents typically lead to localized fires rather than being the top cause of overall residential fires. Proper supervision while cooking is important, but smoking in bed remains a more dangerous, widespread cause of fatal home fires.
C. Lack of smoke detectors: Lack of smoke detectors does not cause fires but delays detection, increasing the risk of injury or death once a fire has already started. While smoke detectors are crucial for early warning and safety, they are not an ignition source that directly leads to the start of residential fires.
D. Placing a space heater 5ft from bed: Placing a space heater 5 feet away from a bed is generally considered safe, as heaters need clearance but are unlikely to cause fires at that distance. Improper use of space heaters can be hazardous, but when correctly placed, they are not the primary cause of residential fires compared to smoking in bed.
Correct Answer is "{\"xRanges\":[111.828125,122.828125],\"yRanges\":[106.5,117.5]}"
Explanation
A: Location A is near the infant’s foot, specifically around the ankle. This area is where the posterior tibial or dorsalis pedis pulse would be palpated, not the femoral pulse. These pulses are important for assessing peripheral circulation but are not the primary site for evaluating coarctation of the aorta, which requires checking central pulses like the femoral.
B: Location B is at the upper inner thigh, near the groin, where the femoral artery passes close to the skin surface. This is the correct site for palpating the femoral pulse in an infant. In conditions like coarctation of the aorta, comparing the strength of the brachial and femoral pulses is crucial to detect differences in blood flow between the upper and lower body.
C: Location C is on the upper arm, near the shoulder area, which corresponds to the location for checking the brachial pulse. The brachial pulse is commonly used in infants to assess heart rate, especially during resuscitation efforts. However, it is not the site for assessing femoral pulse strength, which is needed when evaluating for coarctation of the aorta.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
