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 choice B, Serum creatinine. Choice A rationale:
The white blood cell count (WBC) is an important parameter for assessing the body's immune response to infections. While it can provide valuable information about the presence of an infection, it is not directly related to nephrotoxicity. Therefore, it is not the most important laboratory value to review before administering an antibiotic that can cause nephrotoxicity.
Choice B rationale:
Serum creatinine is a crucial laboratory value to assess kidney function. It is a waste product that is filtered by the kidneys, and its level in the blood is a reliable indicator of kidney function. If the serum creatinine level is elevated, it suggests impaired kidney function, which can be a warning sign of nephrotoxicity. Reviewing the serum creatinine level before administering nephrotoxic antibiotics is essential to ensure that the client's kidneys are functioning adequately and to avoid potential harm.
Choice C rationale:
Hemoglobin and hematocrit are indicators of the client's red blood cell count and blood's oxygen-carrying capacity. While these values can provide information about the client's overall health status, they are not directly related to nephrotoxicity. Therefore, they are not the most important laboratory values to review in this particular scenario.
Choice D rationale:
Serum calcium levels are essential for assessing bone health, nerve function, and muscle contractions. However, they are not directly related to nephrotoxicity, and reviewing serum calcium levels alone would not provide sufficient information about kidney function. Hence, it is not the most critical value to review before administering nephrotoxic antibiotics
Correct Answer is A
Explanation
The correct answer is choicea. Teach the client to use a straw when taking the medication to reduce further tooth staining.
Choice A rationale:
Using a straw when taking liquid iron preparations helps minimize contact with the teeth, thereby reducing the risk of staining.
Choice B rationale:
While tooth discoloration can indicate that the iron is being absorbed, it is not a desired effect and should be managed to prevent cosmetic concerns.
Choice C rationale:
Assessing for mouth or gum pain and difficulty swallowing is important but not directly related to the issue of tooth staining.
Choice D rationale:
Advising the client to withhold doses without consulting a healthcare provider could lead to non-compliance and inadequate treatment of iron deficiency.
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