While ambulating in the hallway following an appendectomy yesterday, a client complains of chest tightness and shortness of breath. Which action should the practical nurse (PN) implement first?
Have the client sit down in the hall.
Assist the client back to the room.
Administer sublingual nitroglycerin.
Obtain a 12-lead electrocardiogram.
The Correct Answer is A
The correct answer is choice A: Have the client sit down in the hall.
Choice A rationale: The PN should first have the client sit down to help alleviate the client's chest tightness and shortness of breath. Sitting down allows for better lung expansion and reduces the risk of falling due to dizziness or lightheadedness. This is the most appropriate initial action in response to the client's complaint.
Choice B rationale: While assisting the client back to their room is important, the PN should first ensure that the client is sitting down to help manage their symptoms. After the client is seated and more stable, the PN can then assist them back to their room for further assessment and intervention.
Choice C rationale: Administering sublingual nitroglycerin may be appropriate if the client is experiencing cardiac-related chest pain. However, the PN should first have the client sit down and gather more information about their symptoms before administering any medications.
Choice D rationale: Obtaining a 12-lead electrocardiogram can help assess the client's cardiac status, but it is not the first action that the PN should take in this situation. Ensuring the client's safety and managing their symptoms are immediate priorities. The PN can consider obtaining an electrocardiogram after addressing the client's immediate needs and assessing their condition further.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A. Temperature. Choice A rationale:
The practical nurse (PN) should complete the data collection for temperature first. A large amount of sanguineous drainage on the abdominal incision dressing could indicate possible infection or a change in the client's condition. Elevated temperature may be an early sign of infection, which requires immediate attention and appropriate intervention.
Choice B rationale:
Assessing the pain scale is important, but it can be addressed after completing the data collection for temperature. Pain assessment is essential for providing appropriate pain management, but it is not the most urgent concern when there is a significant amount of drainage from the incision site.
Choice C rationale:
Checking bowel sounds is relevant in postoperative care, but it is not the priority at this moment. Abdominal incision drainage takes precedence as it may indicate a more critical issue that requires immediate attention.
Choice D rationale:
Monitoring blood pressure is essential, but it is not the most immediate concern in this scenario. A large amount of sanguineous drainage from the abdominal incision takes precedence over blood pressure monitoring at this time.
Correct Answer is C
Explanation
The correct answer is choice C. Suction the oral and nasal passages.
Choice A rationale:
Turning the infant onto the right side may not be the most appropriate intervention for cyanosis caused by regurgitation. Cyanosis signifies a lack of oxygen, and simply changing the infant's position might not address the underlying issue.
Choice B rationale:
Giving oxygen by positive pressure is not the immediate intervention needed for regurgitation-induced cyanosis. While administering oxygen is important, the first step should involve clearing the airway to ensure proper oxygenation.
Choice C rationale:
Suctioning the oral and nasal passages is crucial in this situation as the cyanosis is likely due to the infant's airway being obstructed by regurgitated material. Clearing the airway can restore normal breathing and oxygenation.
Choice D rationale:
Stimulating the infant to cry is not the appropriate action when cyanosis is present. Cyanosis indicates a serious problem with oxygenation, and crying may worsen the situation by further compromising the infant's breathing.
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