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A nurse is caring for a client who suddenly develops chest pain and dyspnea. Which of the following actions should the nurse take first

A.

Place the client on bedrest.

B.

Obtain the client's ABG levels.

C.

Elevate the head of the client's bed.

D.

Prepare the client for a ventilation-perfusion scan

Answer and Explanation

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.


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Related Questions

Correct Answer is A

Explanation

A. Rigid expectations of behavior: Perpetrators of child abuse often have unrealistic and rigid expectations of children’s behavior. When children do not meet these expectations, it can lead to frustration, anger, and abusive responses from the caregiver.

B. Self-blame for financial problems: While financial stress can be a risk factor for family dysfunction, self-blame alone is not a recognized direct characteristic of child abuse perpetrators. Abusive behavior is more often linked to blaming others and lack of coping skills.

C. Laissez-faire leadership style: A laissez-faire leadership style involves being hands-off or permissive, which is not typically associated with abusive behaviors. Abusers are often controlling and overly strict, not permissive.

D. High self-esteem: High self-esteem is generally associated with healthy interpersonal behavior. Low self-esteem, poor coping mechanisms, and unresolved personal trauma are more commonly seen in those who commit child abuse.

Correct Answer is D

Explanation

A. Provide the client with low-calorie formula: The calorie content of the formula is not typically responsible for diarrhea. Diarrhea is more often related to formula intolerance, contamination, or rapid feeding rates rather than calorie density.

B. Increase the rate of the client's feeding: Increasing the rate can worsen diarrhea by overwhelming the gastrointestinal system, leading to poor absorption and increased fluid loss. Slower rates are often needed if diarrhea occurs.

C. Switch the client to a formula containing less protein: Protein content is usually not the cause of diarrhea. Specialized formulas may be needed for certain conditions, but protein itself is not typically a trigger for diarrhea.

D. Administer the client's formula at room temperature: Cold formula can cause gastric cramping and diarrhea. Administering the formula at room temperature helps reduce gastrointestinal irritation and promotes better tolerance of the feeding.

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