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 A

Explanation

A. The stockings prevent venous stasis. Antiembolism stockings help prevent venous stasis by promoting venous return from the legs to the heart, which helps reduce the risk of deep vein thrombosis (DVT).

B. The stockings prevent varicose veins. Antiembolism stockings are not specifically used to prevent varicose veins. They are primarily used to prevent blood clots and improve circulation after surgery.

C. The stockings replace the need for postoperative leg exercises. Antiembolism stockings do not replace the need for leg exercises. Movement and exercise are still necessary to promote circulation and prevent DVT.

D. The stockings are used to reduce pain. Antiembolism stockings are not designed to reduce pain. Their main purpose is to prevent blood clots and improve circulation.

A. Use the diaphragm of the stethoscope to listen to the carotid pulsations. B. Count the apical pulsations for a full minute. C. Check the apical pulse with a Doppler device. D. Press the stethoscope firmly against the client's skin.

Correct Answer is B

Explanation

A. Use the diaphragm of the stethoscope to listen to the carotid pulsations. The apical pulse is located at the apex of the heart, not at the carotid artery. This option does not describe the correct location or use of the stethoscope.

B. Count the apical pulsations for a full minute. Counting for a full minute is the correct method for assessing an apical pulse, particularly in clients on cardiovascular medications, to ensure accurate detection of any irregularities.

C. Check the apical pulse with a Doppler device. A Doppler device is typically used to assess peripheral pulses, not the apical pulse. A stethoscope is the appropriate tool for apical pulse assessment.

D. Press the stethoscope firmly against the client's skin. While the stethoscope should be placed firmly enough to hear heart sounds, excessive pressure can distort the sounds and is not necessary.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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