A 40-year-old patient is admitted with sharp, pleuritic chest pain and dyspnea. The nurse observes jugular venous distension and muffled heart sounds on examination. What is the most appropriate initial nursing action for this patient?
Encouraging the patient to take deep breaths and cough
Administering oxygen to maintain adequate oxygenation
Positioning the patient flat in bed to decrease discomfort
Providing the patient with a warm compress to relieve chest pain
Positive Tinel's sign
The Correct Answer is B
A. Encouraging the patient to take deep breaths and cough would not address the underlying cause of the symptoms, which may indicate a more serious condition.
B. Administering oxygen to maintain adequate oxygenation is the most appropriate initial action, as the patient’s symptoms suggest a potentially life-threatening condition like a cardiac tamponade or pulmonary embolism.
C. Positioning the patient flat in bed is not recommended, as it may exacerbate breathing difficulties and
the patient’s distress.
D. A warm compress is unlikely to be beneficial in this acute situation and could delay appropriate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","F","G"]
Explanation
A. Irritable bowel syndrome is not a complication of PUD, as they are different gastrointestinal disorders.
B. Diverticulitis is unrelated to PUD and involves inflammation of the diverticula in the colon.
C. Gastrointestinal bleeding is a common and serious complication of PUD, occurring due to ulceration of the stomach or duodenum lining.
D. Chronic pancreatitis is not a typical complication of PUD, but it involves inflammation of the pancreas, not the stomach or duodenum.
E. Celiac disease is unrelated to PUD and involves an autoimmune reaction to gluten in the small intestine.
F. Perforation of the stomach or duodenum is a severe complication of PUD, leading to a life-threatening condition with leakage of stomach contents into the abdominal cavity.
G. Gastric outlet obstruction occurs when an ulcer causes scarring and narrowing of the pyloric canal, impeding gastric emptying.
H. Appendicitis is unrelated to PUD, as it involves inflammation of the appendix, not the stomach or duodenum.
Correct Answer is D
Explanation
A. A complete blood count (CBC) can be helpful in identifying anemia or infection but does not confirm Helicobacter pylori infection.
B. Serum amylase test helps in diagnosing pancreatitis, not gastritis. It is not appropriate for confirming
H. pylori infection.
C. A fecal occult blood test detects hidden blood in the stool, which may be present in conditions like
gastric ulcers, but it doesn’t specifically diagnose H. pylori infection.
D. The urea breath test is a non-invasive and highly effective diagnostic tool for detecting Helicobacter pylori infection. It helps identify the presence of the bacteria by detecting the breakdown of urea in the stomach, which is metabolized by H. pylori.
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