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: Electroconvulsive therapy (ECT) requires informed consent, as it is a significant medical procedure involving anesthesia and induced seizures. Informed consent is a process where a patient is fully informed about the procedures and risks involved in a treatment and voluntarily agrees to it.
Choice B reason: Nurses cannot share information with a client's family without the client's permission due to confidentiality laws, except in specific circumstances defined by law. Patient information is protected under the Health Insurance Portability and Accountability Act (HIPAA), which requires patient consent for disclosure.
Choice C reason: Patients have the right to refuse medication. This right is part of the patient's autonomy and informed consent process. A mentally competent adult can refuse treatment, even if it may result in serious illness or death.
Choice D reason: The use of restraints in mental health facilities is highly regulated. Restraints may only be used when necessary to prevent immediate harm to the patient or others and must be discontinued as soon as the risk of harm has subsided.
Correct Answer is C
Explanation
Choice A reason: While disintegration indicates a pill is no longer stable, it is not specific to nitroglycerin tablets.
Choice B reason: The absence of a tingling sensation may not necessarily indicate that nitroglycerin tablets need to be replaced, as this sensation can vary.
Choice C reason: Nitroglycerin tablets should be replaced if they smell like vinegar, as this indicates that the medication may have degraded and may not be effective.
Choice D reason: Discoloration can occur due to various reasons and does not specifically indicate that nitroglycerin tablets have lost potency.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today