An emergency department nurse triages clients who present with chest discomfort. Which client would the nurse plan to assess first?
Client who describes intense squeezing pressure across the chest.
Client who reports moderate pain that is worse on inspiration.
Client who reports cramping substernal pain.
Client who describes pain as a dull ache.
The Correct Answer is A
A. This description is indicative of possible myocardial infarction (MI), a life-threatening emergency. Immediate evaluation and intervention, such as administering oxygen, obtaining an EKG, and providing pain relief, are crucial to prevent further damage to the heart and reduce mortality.
B. Moderate pain worse on inspiration suggests pleuritic pain, often associated with conditions like pleuritis or pulmonary embolism, which are serious but generally not as immediately life-threatening as an MI.
C. Cramping substernal pain may indicate a gastrointestinal issue, such as gastroesophageal reflux disease (GERD), which is less urgent than a potential MI.
D. A dull ache may be related to musculoskeletal or gastrointestinal issues and does not suggest the immediate need for intervention seen in MI.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Blurred vision is not a typical symptom of left-sided heart failure.
B. Difficulty breathing while performing activities, such as climbing stairs, is a classic symptom of left-sided heart failure due to pulmonary congestion.
C. Increased water intake is not directly indicative of left-sided heart failure.
D. Nocturia can occur in heart failure, but it is less specific than dyspnea on exertion.
Correct Answer is A
Explanation
A. This statement indicates that the client may not fully understand the care required for the drainage tubes. Drainage tubes typically do not "fall out" on their own; they need to be removed by a healthcare provider. The client should be instructed to care for the tubes, monitor drainage, and report any concerns to their healthcare provider.
B. It is appropriate to measure the drainage each day and report it if it exceeds the expected amount. This helps ensure that the surgical site is healing properly.
C. The client should be cautious with the positioning of the drainage tubes to avoid kinking or pulling, which could interfere with drainage and cause complications.
D. A foul odor from the drainage could indicate an infection, so it is appropriate for the client to contact their primary healthcare provider if this occurs.
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