A nurse is assisting with the care of a client in the emergency department who reports severe radiating chest pain and shortness of breath. The client appears restless, frightened, and slightly cyanotic. The provider prescribes oxygen by nasal cannula at 4 L/min stat, cardiac enzyme levels, IV fluids, and a 12-lead ECG. Which of the following actions should the nurse take first?
Attach the leads for a 12-lead ECG.
Obtain a blood sample.
Initiate oxygen therapy.
Insert the IV catheter.
The Correct Answer is C
Choice A reason: While attaching leads for a 12-lead ECG is important, it is not the most immediate action required for a client showing signs of distress and potential hypoxia.
Choice B reason: Obtaining a blood sample is necessary for diagnosing the cause of chest pain but is not the first priority in an emergency situation.
Choice C reason: Initiating oxygen therapy is the first and most critical step in managing a client with severe chest pain, shortness of breath, and cyanosis to ensure adequate oxygenation.
Choice D reason: Inserting an IV catheter is important for administering medications and fluids but comes after ensuring the client is receiving sufficient oxygen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Gluten is not typically restricted for patients taking MAOIs unless they have a separate condition that requires this diet.
Choice B reason: Extra salt does not interact with MAOIs, so it is not necessary to avoid it unless the patient has other health concerns that require a low-sodium diet.
Choice C reason: Processed lunch meats are high in tyramine, which can cause dangerous interactions with MAOIs, leading to hypertensive crises.
Choice D reason: While caffeine may need to be limited, it is not as critical as avoiding high-tyramine foods like processed lunch meats when taking MAOIs.
Correct Answer is A
Explanation
Choice A reason: The myocardium requires a constant supply of oxygen to function properly. Coronary artery disease (CAD) causes a reduction in blood flow due to narrowed or blocked coronary arteries, leading to a lack of oxygen in the heart muscle, which can result in angina or chest pain.
Choice B reason: While increased cardiac workload can exacerbate chest pain, it is not the primary cause of pain in CAD. The pain is primarily due to ischemia, which is the lack of oxygen and nutrients to the heart tissue due to reduced blood flow.
Choice C reason: Interrupted electrical activity can lead to arrhythmias or heart attack, but it is not the direct cause of pain in CAD. The pain is related to ischemia, not electrical disturbances.
Choice D reason: A lack of nutrients, including oxygen, to the heart does contribute to the pain experienced in CAD; however, the primary factor is the insufficient oxygen supply, which is explicitly stated in choice A.
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