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

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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Correct Answer is C

Explanation

A. Pain radiating down the left arm: Pain radiating to the left arm is more commonly associated with myocardial infarction (heart attack), not a transient ischemic attack (TIA). It indicates cardiac ischemia rather than a temporary disruption in cerebral blood flow.

B. Seizure activity: Seizures are not characteristic of transient ischemic attacks. While seizures can occur after significant brain injury such as a stroke, TIAs typically present with focal neurological deficits that resolve quickly without leading to seizure activity.

C. Sudden loss of vision in one eye: A sudden, temporary loss of vision in one eye (amaurosis fugax) is a classic sign of a TIA. It reflects temporary ischemia in the retinal or cerebral blood vessels and warrants immediate medical evaluation to prevent a full-blown stroke.

D. Epigastric pain: Epigastric pain is usually related to gastrointestinal issues such as gastritis, ulcers, or gallbladder disease. It is not indicative of a transient ischemic attack and would not typically be prioritized in assessing for neurological compromise.

A. "If I decide to get implants in my arm, I will get them replaced every 10 years." B. "If I decide to get pregnant again, tubal reconstruction is a reliable option C. "I get the birth control injection, I will need an injection 4 times a year." D. "If I get an IUD placed. I will not have menstrual bleeding”

Correct Answer is C

Explanation

A. "If I decide to get implants in my arm, I will get them replaced every 10 years.": Contraceptive implants, such as etonogestrel (Nexplanon), typically last about 3 to 5 years, not 10 years. Misunderstanding the replacement timeline could leave a client unprotected against pregnancy if not corrected.

B. "If I decide to get pregnant again, tubal reconstruction is a reliable option.": Tubal ligation is considered a permanent form of contraception. Although tubal reversal surgery exists, it is not always successful and is not a reliable or guaranteed method for restoring fertility.

C. "I get the birth control injection, I will need an injection 4 times a year.": The birth control injection, such as depot medroxyprogesterone acetate (Depo-Provera), is administered every 3 months, which totals about 4 injections per year. This statement shows a correct understanding of the injection schedule.

D. "If I get an IUD placed, I will not have menstrual bleeding.": Some types of IUDs, particularly hormonal IUDs, may reduce menstrual bleeding significantly, but complete absence of bleeding does not occur in all clients. Copper IUDs, in contrast, may actually increase menstrual bleeding and cramping.

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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

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