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 B
Explanation
The correct answer is choiceB. Remove the warm compress.
Choice A rationale:
Turning the lights on in the room would likely exacerbate the resident’s photophobia (sensitivity to light), causing more discomfort.Photophobia is a common symptom of bacterial conjunctivitis, and keeping the room dim can help alleviate this discomfort.
Choice B rationale:
Removing the warm compress is the correct action. Warm compresses can sometimes be used to relieve symptoms of conjunctivitis, but they are generally more appropriate for viral or allergic conjunctivitis.In the case of bacterial conjunctivitis, warm compresses can potentially worsen the infection by providing a warm, moist environment that promotes bacterial growth.Instead, a cool compress is often recommended to reduce inflammation and discomfort.
Choice C rationale:
Elevating the head of the bed can help reduce swelling and promote drainage, but it is not directly related to the immediate relief of eye pain and photophobia in bacterial conjunctivitis.This action might be more relevant for conditions involving fluid retention or respiratory issues.
Choice D rationale:
Offering an oral analgesic could help manage the resident’s pain, but it does not address the underlying issue of the warm compress potentially worsening the bacterial infection.Pain management is important, but it should be combined with appropriate measures to treat the infection and alleviate symptoms.
Correct Answer is B
Explanation
Ask the client to describe what happened.
Calling the agency-based client advocate (Choice A) should not be the first action taken in this situation. While involving an advocate might be necessary at some point, it is more appropriate to address the client's concerns and gather information about the incident first.
Completing a client adverse incident report (Choice C) is an important step to document theevent and any potential issues, but it should not be the first action taken. Before completing the report, the nurse needs to understand the situation from the client's perspective.
Informing the charge nurse of the situation (Choice D) is a reasonable step, but it should not be the first action. It may be necessary to escalate the issue, but understanding the situation from the client's viewpoint should be prioritized.
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