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 C

Explanation

A. Obtain a blood sample. While obtaining a blood sample to check cardiac enzyme levels is important for diagnosing myocardial injury, it is not the priority over oxygen therapy, given the client’s shortness of breath and cyanosis.

B. Insert the IV catheter. IV access is important for administering fluids and medications, but it is not the first priority in this scenario where the client is experiencing respiratory distress.

C. Initiate oxygen therapy. The client shows signs of hypoxia (shortness of breath and cyanosis), and oxygen is crucial for stabilizing oxygen levels and preventing further deterioration of cardiac and respiratory function.

D. Attach the leads for a 12-lead ECG. Attaching the leads for an ECG is essential to evaluate the client's cardiac status, but it is not the most urgent action in the presence of cyanosis and respiratory distress.

A. Fried fish sandwich and potato salad B. Baked turkey and salad C. Biscuits with sausage gravy and sliced tomatoes D. Barbecued ribs and canned baked beans

Correct Answer is B

Explanation

A. Fried fish sandwich and potato salad: Fried foods are high in unhealthy fats, which can increase cholesterol levels and are not recommended for clients after a myocardial infarction.

B. Baked turkey and salad: This is a healthy choice, as baked turkey is low in fat, and a salad provides nutrients without excessive fat or cholesterol, supporting heart health.

C. Biscuits with sausage gravy and sliced tomatoes: Biscuits and sausage gravy are high in saturated fats, which are not appropriate for a heart-healthy diet.

D. Barbecued ribs and canned baked beans: Barbecued ribs and canned baked beans may contain high levels of saturated fats, sugar, and sodium, which are not recommended for someone recovering from a myocardial infarction.

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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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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is reinforcing teaching regarding diet to a client who has had a myocardial infarction. Which of the following diet choices by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

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