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 B
Explanation
A. Dry skin: Dry skin is not typically associated with the disulfiram-alcohol reaction. The primary concerns involve cardiovascular and gastrointestinal symptoms rather than dermatologic effects.
B. Hypotension: Disulfiram causes an intense physical reaction when alcohol is consumed, including symptoms like flushing, nausea, vomiting, hypotension, and potentially life-threatening cardiovascular collapse. Monitoring for hypotension is critical during this reaction.
C. Constipation: Constipation is not a typical side effect of disulfiram-alcohol interaction. Gastrointestinal symptoms such as nausea and vomiting are much more common and more clinically significant.
D. Urinary retention: Urinary retention is not a known reaction to the combination of disulfiram and alcohol. The body’s response focuses more on vascular changes and gastrointestinal distress.
Correct Answer is B
Explanation
A. Allergy to penicillins: Penicillin allergies are important when prescribing beta-lactam antibiotics like amoxicillin, but azithromycin is not a penicillin; it belongs to the macrolide class, so this allergy is not directly relevant.
B. Allergy to macrolides: Azithromycin is a macrolide antibiotic. An allergy to macrolides must be reported immediately because administering azithromycin could trigger an allergic reaction, which could be serious or life-threatening.
C. Allergy to sulfonamides: Sulfonamide allergies are relevant when prescribing medications like sulfamethoxazole-trimethoprim, but azithromycin does not belong to the sulfonamide class.
D. Allergy to tetracyclines: Tetracyclines are a different class of antibiotics, used for infections such as acne or certain respiratory infections. An allergy to tetracyclines is not a concern when administering azithromycin.
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