An emergency department nurse is collecting information from a client who has stable vital signs when their other client begins to report chest pain. Which of the following should be the nurse's priority?

Call the client's home for someone to pick up the client.

Call for a code blue.

Ask another nurse to assess the client who reports chest pain.

Alert the RN to assess the client reporting chest pain

Answer and Explanation

The Correct Answer is C

A. Call the client's home for someone to pick up the client. This is not appropriate in an emergency situation. The client reporting chest pain needs immediate attention, and arranging for pick-up is not a priority.

B. Call for a code blue. Code blue is reserved for clients in cardiac or respiratory arrest. The nurse needs to assess the severity of the chest pain first before calling a code.

C. Ask another nurse to assess the client who reports chest pain. The priority is to ensure that the client reporting chest pain is assessed immediately. Delegating this task to another nurse allows prompt care for the client with potential cardiac issues while ensuring that the first client continues to receive care.

D. Alert the RN to assess the client reporting chest pain: While notifying the RN is important, it may delay the initial assessment and intervention needed for the client with chest pain. Delegating to another available nurse is a more immediate action.

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Correct Answer is B

Explanation

A. S3 heart sound: An S3 heart sound is often associated with heart failure and volume overload, not specifically mitral stenosis.

B. Dyspnea on exertion: Dyspnea on exertion is a classic symptom of mitral stenosis. The narrowing of the mitral valve restricts blood flow from the left atrium to the left ventricle, causing pulmonary congestion and shortness of breath, especially during physical activity.

C. Cyanosis: While cyanosis can occur in advanced stages of heart disease, it is not a primary symptom of mitral stenosis. It indicates severe oxygenation issues, which are usually late findings.

D. S4 heart sound: An S4 heart sound is typically associated with left ventricular hypertrophy, which can occur in advanced cases of mitral stenosis. However, it's not a specific early manifestation of the condition.

A. Obtain platelet aggregation studies to confirm DVT B. Schedule deep tissue massage with physical therapy. C. Arrange for a venous duplex ultrasound. D. Monitor Homan's sign.

Correct Answer is C

Explanation

A. Obtain platelet aggregation studies to confirm DVT. Platelet aggregation studies are not used to diagnose deep vein thrombosis (DVT). They are more relevant for evaluating platelet function and clotting disorders.

B. Schedule deep tissue massage with physical therapy. Deep tissue massage is contraindicated in clients suspected of having DVT, as it could dislodge the clot and cause a pulmonary embolism or other complications.

C. Arrange for a venous duplex ultrasound. A venous duplex ultrasound is the standard diagnostic test used to confirm DVT. It visualizes the veins and assesses blood flow, helping to detect the presence of a clot.

D. Monitor Homan's sign. Homan’s sign (pain in the calf with dorsiflexion of the foot) was once considered a diagnostic indicator of DVT, but it is no longer considered reliable due to its low sensitivity and specificity. Therefore, it is not routinely used for DVT diagnosis.

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An emergency department nurse is collecting information from a client who has stable vital signs when their other client begins to report chest pain. Which of the following should be the nurse's priority?

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An emergency department nurse is collecting information from a client who has stable vital signs when their other client begins to report chest pain. Which of the following should be the nurse's priority?