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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

The correct answer is Choice C:

Gather the procedure tray and equipment. Choice A rationale:

Placing the client in an orthopneic position (sitting upright and leaning forward) is not necessary for a thoracentesis procedure. The position may be uncomfortable for the client and does not facilitate the procedure.

Choice B rationale:

Keeping the client NPO (nothing by mouth) and encouraging them to void before the procedure is not directly relevant to a thoracentesis. NPO status might be indicated for other procedures requiring anesthesia but not for a bedside thoracentesis.

Choice C rationale:

This is the correct choice. The PN should prepare by gathering the procedure tray and equipment before the healthcare provider arrives to perform the thoracentesis. This ensures that all necessary items are readily available for the procedure.

Choice D rationale:

Cleansing the site and covering it with a sterile towel is a task usually performed by the healthcare provider who will be performing the thoracentesis. The PN's role is to prepare the necessary equipment and assist the provider during the procedure.

A. Never scratch under the cast. B. Expect some increase in pain. C. Apply a cold pack to any "hot spots”. on the cast. D. Keep the left leg in a dependent position

Correct Answer is A

Explanation

The correct answer is choice A: Never scratch under the cast.

Choice A rationale:

It is important not to scratch under the cast because inserting objects can lead to skin injury and infection. If itching occurs, blowing cool air from a hair dryer into the cast is recommended.

Choice B rationale:

While mild swelling and some discomfort are common after a cast is applied, patients should not expect an increase in pain. Persistent or severe pain could indicate complications such as increased swelling, decreased blood flow, or pressure on nerves and should be evaluated by a healthcare provider.

Choice C rationale:

Applying a cold pack to “hot spots” on the cast is not recommended as it can lead to moisture accumulation and skin problems. Instead, to manage swelling and discomfort, ice can be applied over the cast, covered with a thin towel, for 20 minutes every two hours while awake during the first 48 hours.

Choice D rationale:

Keeping the injured leg in a dependent position is not advised because it can increase swelling and pain. The affected limb should be elevated above the level of the heart to reduce swelling and promote healing.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is scheduled for a thoracentesis that will be done at the bedside. What should the practical nurse (PN) prepare before the healthcare provider arrives on the unit to perform the procedure?

Correct Answer is C

Explanation

A client with a compound fracture of the left ankle is being discharged with a below-the-knee cast. Which instruction should the practical nurse (PN) provide to the client prior to discharge?

Correct Answer is A

Explanation

The practical nurse (PN) and unlicensed assistive personnel (UAP) enter a client's room and find the client lying on the bed. The PN determines that the client is unresponsive. Which instruction should the PN give the UAP first?

The practical nurse (PN) believes that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Which action should the PN take?

The practical nurse (PN) is reinforcing dietary instructions with a client who has renal disease regarding the need to limit salt intake. Which selections for a lunch meal indicate to the PN that the client is following the diet plan? (Select all that apply.).

A client is admitted for treatment of Addison's crisis. Which finding is most important for the practical nurse (PN) to report to the charge nurse? Reference Range: Glucose [Reference Range: 0 to 50 years: less than 140 mg/dL or less than 7.8 mmol/L].

A 70-year-old male client who is convalescing from a hip replacement is identified as being at risk for developing a pressure ulcer. Which physical characteristic of aging contributes most to this risk factor?

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?

A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. Which immediate intervention should the practical nurse (PN) implement?

The practical nurse (PN) is assigning care for a group of clients on the urology medical unit. Which client care interventions should the PN assign to the unlicensed assistive personnel (UAP)? (Select all that apply.).